Inspection on 25/05/07 for The Haven

This inspection was carried out on 25th May 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 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 22/07/08

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Haven 191 Havant Road Drayton Portsmouth Hampshire PO6 IEE Lead Inspector Laurie Stride Unannounced Inspection 25th May 2007 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.V336174.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.V336174.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Haven Address 191 Havant Road Drayton Portsmouth Hampshire PO6 IEE 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.V336174.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd November 2006 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. The home’s fees are currently £442.00 per week. The Haven DS0000011671.V336174.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit was carried out on the 25th May 2007 as part of the key inspection of this service. Prior to the visit the registered manager had completed an annual quality assurance assessment (AQAA). Two of the people who live in the home had returned postal survey questionnaires, one assisted by a family member or representative. Four other friends or relatives of people who use the service and a professional who visits the home also returned survey questionnaires. This information, together with the previous inspection report and information gathered during the visit, provide the evidence on which this current report is based. The inspection visit took place over approximately seven hours and the home’s registered manager assisted the inspector throughout. During the visit it was possible to meet some of the people who live in the home and talk in depth with two of them. The inspector also spoke with two members of the staff team, the registered manager and the owner of the service, read samples of the home’s records and viewed parts of the premises. What the service does well: What has improved since the last inspection? More staff are deployed at busy times of the day in order to be more responsive to the needs of people who use the service. Quality assurance questionnaires are being used on a more frequent and regular basis, in order to seek the views of people who use the service. The home has taken steps to ensure that the account used to deposit residents’ finances is secure in the event of insolvency. Staff members receive regular supervision. The Haven DS0000011671.V336174.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Haven DS0000011671.V336174.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Haven DS0000011671.V336174.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. 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. Prospective people to use a service and their representatives have the information needed to choose a home that will meet their needs and also have their needs assessed prior to admission. EVIDENCE: People who returned survey questionnaires said they had received sufficient information to make a choice about moving to the home. In discussion with people who live in the home, one person said they had visited with relatives before making a decision to use the service. Records of admission were seen in respect of a person who came to live in the home since the last inspection and showed s/he had been assessed as to what his/her individual needs were. The home’s owner had completed the assessment, although it is usually the registered manager who carries out this The Haven DS0000011671.V336174.R01.S.doc Version 5.2 Page 9 task. The information gathered during the assessment had been used to complete a written care plan for this person. Through discussion with people who live in the home and the information gathered by survey, it was evident that residents and their representatives felt that they receive the care and support they need. The home does not provide for intermediate care, therefore this standard is not applicable. The Haven DS0000011671.V336174.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service generally receive appropriate health and personal care, based on their individual needs. However care plan records still do not clearly show how this is being achieved for each person. Improvements in medication practices are required to ensure that people who use the service are better safeguarded. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Each person who lives in the home has a care plan and the inspector examined a sample of three of these plans during the visit to the home. A full assessment of each individuals needs had been carried out prior to admission. Care plans include manual handling assessments and risk assessments and are reviewed once a month. Residents had recorded their signature at regular intervals acknowledging their agreement to the care plan. The Haven DS0000011671.V336174.R01.S.doc Version 5.2 Page 11 Care plans, which detail individual needs, are not recorded in sufficient detail for the reader to be able to tell what it is that staff should be carrying out and how this will be done. This was also identified at the previous inspection. The registered manager explained that there is a regular team of staff who are aware of individual’s needs. However, in the event of agency staff being used, there being new staff or an emergency requiring the person’s notes to be available, detailed care plans with clear methodologies would ensure the individual’s needs are able to be consistently met. In the sample of records seen, risk assessments were not always clearly linked to the individuals care plans. For example a risk assessment form indicated no risks to an individual in relation to falls but the care plan showed there to be an element of risk, through mobility issues and the use of bed-rails. The registered manager said that the use of bed-rails was on the advice of the District Nurse. There was no written agreement in place between the individual and his/her representatives, the home and healthcare professionals, to show how this decision had been reached and that it is in the person’s best interests. The individual concerned said s/he did not mind the rails being used. These matters were discussed with the registered manager who said that care plans would include more detail. The previous requirement has been repeated. Records showed that general health care needs are addressed with regular appointments being arranged for each person with the optician, chiropodist and general practitioner (GP). Care staff described how the home liaises with specialist health care professionals such as the continence advisor. Through discussion with people who live in the home and the information gathered by survey, it was evident that residents and their representatives felt that medical support is received when it is needed and that the home gives individuals the care and support that is expected or agreed. Staff treat people who live in the home with respect and respond flexibly and in good time to individuals’ changing needs. The inspector examined the medication practices in the service and looked at the storage and recording of medication. Residents’ medication is stored appropriately and the home keeps records of medication administered and disposed of in the home. In one of the samples of medication records seen, the individual was being given an analgesic on an ‘as and when required’ basis by staff, but this was not written up on the individual medication records. The deputy manager said this would be done. Another resident had been refusing a prescribed medication and this was being recorded. This had resulted in there being approximately three months supply, by the deputy manager’s calculation, of unused medication stored in the home, which had not been returned to the chemist in The Haven DS0000011671.V336174.R01.S.doc Version 5.2 Page 12 line with the home’s medication policy. The deputy manager telephoned the pharmacy at the time of the visit and arranged for the safe disposal of the medication. After the inspection visit the registered manager wrote to the Commission for Social Care Inspection, confirming that the unused medication had been safely disposed of and staff at the home had been informed of the need to ensure that the relevant procedures are adhered to. Subsequent to this letter, the registered manager wrote stating that an investigation had found that there was in fact only one months supply. The home was supporting a resident to manager his/her own medication independently, with the agreement of their GP. A risk assessment had been drawn up and was being kept under review and the individual had been provided with a lockable facility to store their medication. The Haven DS0000011671.V336174.R01.S.doc Version 5.2 Page 13 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to make choices about their lifestyle and receive a well-balanced and varied diet reflecting their likes and dislikes. Social and recreational activities generally meet individual’s expectations and the home seeks people’s views on these. Greater attention to record keeping would further demonstrate that residents’ needs in these areas are being addressed. EVIDENCE: Comments received through discussion and the survey, from residents and their visitors, confirmed there are activities arranged by the home that residents can take part in and that the home supports individuals to live the life they choose. One person said they preferred not to join in the activities offered and chose to spend time on their own in their room. On the morning of the visit the owner was facilitating an arts and crafts session for a number of people who use the service. There are also weekly bingo sessions and parties are held on special occasions such as Easter and during the summer. One person commented that the home had brought in an The Haven DS0000011671.V336174.R01.S.doc Version 5.2 Page 14 entertainer and a dance group at Christmas. The home has a quality assurance questionnaire that asks people about what activities they are interested in. The registered manager described how residents have been reluctant to go on outings when these have been arranged. The sample of care records seen showed that people had opportunities to socialise and that visitors are welcome. These did not however provide a clear record of what activities had been offered and which activities individuals chose to take part in. More evidence is needed in care plans to show that residents are being offered opportunities for activities and mental stimulation on a daily basis. This was discussed with the registered manager who said that care plans would include more detail. After the inspection visit the registered manager wrote to the Commission for Social Care Inspection, stating that the home has initiated a record of activities. The results of the survey showed that friends and relatives of people who use the service felt that the home supports individuals to keep in touch with them. One person’s relative said that the home provided a friendly atmosphere and took into account the needs of people who had travelled a long way to visit, by offering refreshments. Comments received from people who use the service showed that they liked the food provided in the home and thought this had improved. The owner has meetings with residents and meals are discussed, providing opportunity for people to inform the home of their preferences. Individuals confirmed that alternatives to the menu are always offered and said that they ‘can have what they want’ and ‘get what they like’. Fresh fruit was seen to be available between meals in the dining room. The Haven DS0000011671.V336174.R01.S.doc Version 5.2 Page 15 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. People who use the service feel able to express their concerns and are protected by the home’s policies and procedures. This will be enhanced by the further training planned for staff. EVIDENCE: Residents who were spoken with or who returned questionnaires felt they are treated with respect and confirmed that staff listen and act on what they say. They were aware of the complaints procedure and felt comfortable about taking any concerns to the manager or staff. The home has a complaints logbook and this showed that the service had taken appropriate action and responded to concerns expressed by external agencies earlier in the year. The Commission for Social Care Inspection (CSCI) were also aware of two other separate concerns/complaints reported by members of the public since the time of the last inspection. One of these had been reported to CSCI who had forwarded the concerns to the provider. The provider had responded in writing to CSCI, however there was no record of this in the complaints logbook. The other concern had been sent in writing to the provider and copied to CSCI but there was also no record of this in the home’s logbook. The Haven DS0000011671.V336174.R01.S.doc Version 5.2 Page 16 The registered manager said she would look into the matter of the missing records. After the inspection visit the registered manager wrote to the Commission for Social Care Inspection, providing evidence that the missing records were held in the home and had been placed in individual resident’s files at the time of the visit. The provider needs to ensure that all complaints and subsequent actions are recorded in the home’s complaints log. The home has copies of the local authority safeguarding adults procedures and a whistle blowing policy. The registered manager said that all staff had received training in adult protection matters and it was planned that further training, possibly by an external organisation, would be arranged. Staff spoken to were aware of their responsibilities in relation to reporting any suspected or actual incident of abuse, but were not as clear on the recording aspects or about whose responsibility it is to investigate such matters. This was discussed with the registered manager, who said she would re-visit the safeguarding adults procedures with staff in supervision sessions. Discussion with people who use the service confirmed that they feel safe in the home and feel free to express themselves. The home’s quality assurance questionnaire also encourages people to comment about the service. The Haven DS0000011671.V336174.R01.S.doc Version 5.2 Page 17 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 good. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that is appropriate to the specific needs of the people who live there. The views of all residents should be sought and taken into account in relation to individuals’ keeping pets in the home. EVIDENCE: People who use the service were observed using the communal areas of the home. There is a lounge and dining area on each floor. The one on the first floor can be accessed by a passenger lift or the stairs. A number of residents’ bedrooms were seen and these were generally clean, well maintained and personalised with the occupants’ possessions, giving a homely feel. The one exception was an individual’s bedroom carpet, which was quite heavily stained and a wall in this room was in need of re-painting. The The Haven DS0000011671.V336174.R01.S.doc Version 5.2 Page 18 registered manager said she would ensure this was on the maintenance list. It was noted that the home’s maintenance person cleaned the carpets as part of the maintenance cycle. After the inspection visit the registered manager wrote to the Commission for Social Care Inspection, confirming that the carpet had been cleaned and the paintwork scheduled for refurbishment in the next few days. The home also keeps a record of bedroom checks to ensure that when people move in, their bedroom is comfortable and clean and suits their needs. All bedrooms have an en suite toilet. In addition to this, the home has 3 communal bathrooms, which include a ‘walk-in’ shower and a bath with a hoist. The home also has a number of aids for those with mobility difficulties including a mobile hoist, a stand aid and slings. Staff receive training in moving and handling. Comments from people who use the service confirmed that they are satisfied with the furniture and fittings and the general comfort of their surroundings. Other comments from some of the people who visit the home suggested that cleaning and response times to routine maintenance could be improved. The home has a laundry equipped with washing machines that have appropriate disinfection programmes. The laundry room was clean and the floors and walls are readily cleanable to ensure the chances of infection and cross contamination is reduced. There are infection control procedures in place that are supported by relevant staff training. The inspector observed staff using appropriate protective equipment such as gloves and aprons. At the start of the inspection visit, it was noted that a dog was tethered to a chair in the main lounge. The registered manager said that the dog belongs to a resident in the home and stays in the bedroom unless on a lead. A written risk assessment was seen and the residents’ family provide daily walks for the animal. Through discussion with individuals in the home it was apparent that while not everyone is an ‘animal lover’ the dog is ‘no trouble’. Some concern was raised about it being in the lounge in hot weather. The registered manager said there is also a small lounge area that is cooler and some residents are happy to spend time there with the dog. While being able to keep their pet is obviously important to the individual concerned, it was also apparent that some but not all residents have been asked for their opinion about this arrangement. This was discussed with the registered manager who agreed to ensure that all residents’ views are documented and taken into account. It was also advised that the home seeks the advice of the environmental health officer. The Haven DS0000011671.V336174.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements have been made in the way the home deploys staff to meet residents’ needs and staff are further supported in this through induction and training. The home’s recruitment procedures protect people who use the service. EVIDENCE: Since the last inspection the home has reviewed the way staff are deployed in order to ensure that residents needs are met at busy times of the day. This meets a previous requirement. The rota showed that a member of the staff team comes to work early or stays later to assist the core staff of two who are busy with tasks involving moving and handling. This means that there is a staff member available to respond to other residents needs at these times. One of these additional staff is a cleaner and would not be able to assist with personal care, but could alert the core staff if needed. The registered manager said this system had been implemented in the last month and would be kept under review. In addition to care staff the home employs a cook and two cleaners. Night duties are covered by one staff member who is awake and another who sleeps in. The registered manager and owner are also in the home between 9am and 2pm during the week and also at other times if needed. The Haven DS0000011671.V336174.R01.S.doc Version 5.2 Page 20 Training is provided for staff, including the following subjects: medication, dementia, food hygiene, infection control, NVQ level 2 and 3, and communicable diseases. The registered manager reported that, of 22 care staff, 6 have obtained an NVQ level 2 or 3 and another 9 are working toward NVQ awards. Both groups combined equal 64 of staff. Through discussion care staff confirmed the provision of training in NVQ level 2 and 3 in care, as well as other courses. Evidence was seen that future training is booked, including a course on sexuality and the older person, palliative care and managing behaviour that is challenging. The home has a staff induction programme and checklist and the registered manager was advised and agreed to check that this is in line with the Skills for Care common induction standards. A sample of two staff member’s files was seen in relation to the home’s recruitment procedures. Both files contained evidence that the required checks were being carried out, including criminal records bureau (CRB) and protection of vulnerable adults (POVA) checks, two written references and application forms with employment histories. The Haven DS0000011671.V336174.R01.S.doc Version 5.2 Page 21 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 adequate. This judgement has been made using available evidence including a visit to this service. People who live in the home are supported by a service that is managed in a generally effective and open manner. However, there are some areas that the home needs to address to fully demonstrate that the service is run in the best interests of the people who live in the home. EVIDENCE: The registered manager is a registered nurse and has NVQ level 4 in management. In addition to this, she regularly attends training courses with other members of the staff team to update her skills. Staff members confirmed that the management are supportive and accessible. The Haven DS0000011671.V336174.R01.S.doc Version 5.2 Page 22 The home uses several methods of monitoring its own performance including regular checks of the physical environment. Questionnaires are provided to residents annually in order to check their views on the service provided by the home. This is done in two parts, one half of the resident group receive a questionnaire every six months. Evidence was also seen of regular meetings between the owner and people who use the service. The minutes of staff meetings reflected comments made by residents in their questionnaires, demonstrating that people’s views were being acted on. As identified in previous sections of this report, the management need to ensure that all residents’ views are documented and taken into account in relation to individual’s keeping pets in the home. Other areas that need to be addressed are care plan documentation and medication procedures. The provider needs to ensure that all complaints and subsequent actions are recorded in the home’s complaints log. The service provider is not in day-to-day charge of the care home, which is the role of the registered manager, but is in the home on most days and this is recorded on the rota. There were no recent regulation 26 reports in the home and the registered manager confirmed that the provider has not carried out regulation 26 reports for this year. The home handles some of the residents’ finances and holds it on their behalf in an account. This is recorded with any transactions, balances, deposits and withdrawals detailed. Following a previous recommendation the home has taken steps to ensure that the account used to deposit residents’ finances is secure in the event of insolvency. Staff members confirmed that they receive regular supervision, about every six weeks and appraisals. Further evidence of this was obtained through the home’s records. This meets a previous recommendation. Evidence was seen that the home promotes safe working practices. The home’s appliances are serviced on a regular basis and certificates for this were on file. The records for fire drills and the maintenance of fire equipment were up-to-date. Staff members receive training in first aid, food hygiene, infection control and moving and handling. The Haven DS0000011671.V336174.R01.S.doc Version 5.2 Page 23 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 2 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 3 X X X X X X 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 X 2 X 3 X X 3 The Haven DS0000011671.V336174.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Care plans must detail how personal and health care needs are being met, including specific actions and guidance for staff to follow. This requirement was previously made on 02/11/06 and should have been achieved by 02/01/07. 2. OP7 17 (1) Schedule 3 13(2) Care plans must contain a record of any agreements relating to the use of bed-rails. The home must ensure that all individual’s medication is fully recorded. 24/08/07 Timescale for action 24/08/07 3. OP9 30/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. The Haven Refer to Good Practice Recommendations DS0000011671.V336174.R01.S.doc Version 5.2 Page 25 1. Standard OP33 All residents’ views should be documented and taken into account in relation to individual’s keeping pets in the home. The Haven DS0000011671.V336174.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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.V336174.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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