Care Home: Derbyshire Haven Care Home

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What the care home does well What has improved since the last inspection? Care plans and risk assessments have been improved to make them more `person centred`. This means that the care provided is flexible and designed to meet the particular needs of each individual resident. A hairdressing salon has been created on the first floor. The home`s courtyard has been completely re-designed. The work was funded with a `Dignity in Care` grant. The courtyard, which is secure and secluded, now features a fountain, a raised flowerbed (to make it easier for wheelchair users to see and smell the flowers), and a seating area. Following a requirement made at the last inspection, recruitment procedures have been improved and no one is allowed to start work in the home until all the necessary background checks have been done. This will help to ensure residents are safeguarded. The Manager has introduced a record book to collect residents` views on the home. She has regular informal discussions with the residents, both as a group and on a one-to-one basis, and writes down any comments or suggestions they have. Changes had been made as a result of what residents had said. For example, residents had asked for rabbit stew and this had been provided.Since the last inspection the reporting of Regulation 37s has improved. Records showed that all untoward incidents, for example falls, are being reported to CSCI as required. CARE HOMES FOR OLDER PEOPLE Derbyshire Haven Care Home 2 Brendon Road Wollaton Nottingham NG8 1HW Lead Inspector Kim Cowley Unannounced Inspection 5th August 2008 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Derbyshire Haven Care Home DS0000002195.V370040.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. Derbyshire Haven Care Home DS0000002195.V370040.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Derbyshire Haven Care Home Address 2 Brendon Road Wollaton Nottingham NG8 1HW 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) 0115 9282110 0115 9133595 barbarahadfield@hotmail.com The Trustees of the Lucy Derbyshire Annuity Fund Barbara Mary Hadfield Care Home 12 Category(ies) of Old age, not falling within any other category registration, with number (12) of places Derbyshire Haven Care Home DS0000002195.V370040.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 19th July 2007 Brief Description of the Service: Derbyshire Haven is registered to provide care and accommodation for up to 12 older people. The home was purpose built in 1974 and is situated near to Wollaton Park. It is owned by the Lucy Derbyshire Annuity Fund Trust, a registered charity. The home is close to local shops and other amenities, and there are nearby bus services to the centre of Nottingham. Most of the bedrooms are large, with both sleeping and daily living areas, and have ensuite showers and toilets. The home has two floors and the first floor can be accessed by a lift. There is a communal lounge and dining room with access to a small secluded patio garden at the rear of the home. The fees are £420 per week. Further information about the home is available from the Manager. Derbyshire Haven Care Home DS0000002195.V370040.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 stars. This means the people who use this service experience good quality outcomes. This was a key inspection that included a visit to the home and inspection planning. Prior to the visit, we (throughout the report the use of ‘we’ indicates the Commission for Social Care Inspection) spent half a day reviewing information relating to the home. During the course of the inspection, which lasted five hours, we checked the ‘key’ standards as identified in the National Minimum Standards. This was achieved through a method called case tracking. Case tracking means we looked at the care provided to three residents living at the home by meeting them; talking with the staff who support their care; checking records relating to their health and welfare; and viewing their personal accommodation as well as communal living areas. Other issues relating to the running of the home, including health and safety and management issues, were examined. We also talked to three other residents, two relatives, the Manager, a senior carer, and a care assistant. What the service does well: Devonshire Haven provides homely and comfortable accommodation to its residents. The entrance is welcoming, with information about the home’s history on the walls and a picture of its benefactor. A visitor described the home as, ‘Very easy going. A good atmosphere. Smells nice. I’m really happy with this home. There’s company for my relative and peace of mind for me.’ There is a large lounge and an adjacent dining room where residents sit in groups of four at mealtimes. The bedrooms are spacious and most have room for both a living and a sleeping area. All areas inspected were immaculately clean and tidy. A relative told us, ‘This home always look lovely and is clean from top to bottom.’ Residents and relatives told us care needs were always met promptly. One resident said, ‘The staff come so quickly when you ring the call bell that I wonder if they’re waiting behind the door!’ Another commented, ‘The night staff are amazingly quick to respond to the call bell.’ And a relative told us, ‘My relative never has to wait to be taken to the bathroom.’ Derbyshire Haven Care Home DS0000002195.V370040.R01.S.doc Version 5.2 Page 6 The staff we met were friendly and helpful. We saw they got on well with the people who live in the home. All the residents and relatives we talked to praised the staff team. One resident said, ‘The staff are very respectful and we have a good laugh with them too’, and another commented, ‘The staff will do anything you ask.’ A relative told us, ‘The staff are brilliant and have a good rapport with my relative.’ The home provides activities for residents including quizzes, a weekly keep fit class run by a physiotherapist, and visiting musical entertainment. All the residents and relatives we spoke to praised the food. One resident told us, ‘The food is marvellous. It’s nice to come down to breakfast and be given a choice of six cereals!’ A relative said, ‘There’s good variety of food and my relative is always full. It always looks lovely – when I see it I think, “I’d like to eat that!”’ The Manager is experienced and knowledgeable about all the residents who live in the home and how best to meet their needs. One of the residents told us, ‘The Manager is very nice – she is always there for me, asking how I am, and she looks after her staff too.’ What has improved since the last inspection? Care plans and risk assessments have been improved to make them more ‘person centred’. This means that the care provided is flexible and designed to meet the particular needs of each individual resident. A hairdressing salon has been created on the first floor. The home’s courtyard has been completely re-designed. The work was funded with a ‘Dignity in Care’ grant. The courtyard, which is secure and secluded, now features a fountain, a raised flowerbed (to make it easier for wheelchair users to see and smell the flowers), and a seating area. Following a requirement made at the last inspection, recruitment procedures have been improved and no one is allowed to start work in the home until all the necessary background checks have been done. This will help to ensure residents are safeguarded. The Manager has introduced a record book to collect residents’ views on the home. She has regular informal discussions with the residents, both as a group and on a one-to-one basis, and writes down any comments or suggestions they have. Changes had been made as a result of what residents had said. For example, residents had asked for rabbit stew and this had been provided. Derbyshire Haven Care Home DS0000002195.V370040.R01.S.doc Version 5.2 Page 7 Since the last inspection the reporting of Regulation 37s has improved. Records showed that all untoward incidents, for example falls, are being reported to CSCI as required. 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. Derbyshire Haven Care Home DS0000002195.V370040.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 Derbyshire Haven Care Home DS0000002195.V370040.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): Quality in this outcome area is good. Residents’ needs are assessed prior to admission to ensure the home is suitable for them. This judgement has been made using available evidence including a visit to this service. (Standard 3 was inspected.) EVIDENCE: Residents and relatives talked to us about how they chose to come to Derbyshire Haven. One resident said, ‘I saw it and I loved it and I wanted to move in straight away.’ A relative told us, ‘This home was recommended to us by a friend. We turned up unannounced and were immediately impressed.’ Potential residents and their families/representatives are invited to visit as often as they like to help them decide if the home is right for them. People who are interested in coming to live in the home are assessed by the Manager to ensure their needs can be met. We looked at three assessments belonging to the case tracked residents and saw they were clear and detailed, covering all potential areas of need. Staff use these when residents first move in to make sure they get the care they need. Derbyshire Haven Care Home DS0000002195.V370040.R01.S.doc Version 5.2 Page 10 Standard 6 was not inspected, as this home does not provide intermediate care. Derbyshire Haven Care Home DS0000002195.V370040.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): Quality in this outcome area is good. Staff in the home, and in the wider community, meet residents’ health and personal care needs. This judgement has been made using available evidence including a visit to this service. (Standards 7, 8, 9, and 10 were inspected.) EVIDENCE: Since the last inspection care plans and risk assessments have been improved to make them more ‘person centred’. This means that the care provided is flexible and designed to meet the particular needs of each individual resident. For example, one resident doesn’t have his breakfast until 10 am because he likes to have a shower first. The residents and relatives we spoke to said care needs were always met promptly. One resident said, ‘The staff come so quickly when you ring the call bell that I wonder if they’re waiting behind the door!’ Another commented, ‘The night staff are amazingly quick to respond to the call bell.’ And a relative told us, ‘My relative never has to wait to be taken to the bathroom.’ Residents and their relatives are consulted when care plans are written and asked to sign them to show their agreement. This helps to ensure that residents receive the support they need when they want it. Derbyshire Haven Care Home DS0000002195.V370040.R01.S.doc Version 5.2 Page 12 Some of the residents who live at Derbyshire Haven suffer from confusion and mild dementia. This has lead to occasional episodes of challenging behaviour. Although staff have responded as best as they could, they have not had care plans to guide them. Care plans must be put in place for any resident who is challenging. This will help to ensure that staff know what to do should an incident occur. Derbyshire Haven aims to provide life-long care for the people who live there. Although not a nursing home, the equipment and facilities make it possible for people who develop nursing needs to stay at the home with the help of health care professionals. If a resident is nearing the end of their life, staff work closely with palliative care nurses to ensure that they do not have to go into hospital if they don’t want to. Specialist equipment and resources can be accessed where necessary, and services such as ‘hospice at home’ accessed where sitters can be provided to be with the resident at all times if this is what they would like. Records showed that residents’ health care needs are closely monitored and GPs and other health care professionals contacted when necessary. We saw good evidence of preventative work being carried out by staff at the home, for example skin care in conjunction with the tissue viability nurse to help prevent residents developing pressure sores. Medication is safely stored and administered with the support of the home’s contract pharmacist, who also provides advice and staff training. All the residents we spoke to said they were happy with how their medication was managed. One resident told us, ‘When I was at home I was always forgetting to take my medication. Now I don’t have to worry because the staff remember for me. They come and give me my medication when I need it.’ During their induction staff are trained to treat residents with respect and maintain their privacy. The Manager said that as Derbyshire Haven is a small home both she and her Deputy work closely with the staff team and lead by example. A recent survey carried out by the home on ‘Privacy and Dignity’ showed all residents were satisfied with how respectfully the staff cared for them. Derbyshire Haven Care Home DS0000002195.V370040.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. Residents’ social and cultural needs are identified and met. Varied and wholesome food is served. This judgement has been made using available evidence including a visit to this service. (Standards 12, 13, 14, and 15 were inspected.) EVIDENCE: The home activities for residents to take part in if they wish. In the afternoon residents play group games in the lounge. The Manager said that at present ‘hangman’, played on a large white board, is popular. Other activities include: • • • • • • quizzes, board games, and a throwing game with a target mat a weekly keep fit class run by a physiotherapist visiting musical entertainment communion in the home once a month and some residents go out to church reading – the home has a small library of large print books hairdressing – since the last inspection a new hairdressing salon has been created on the first floor Derbyshire Haven Care Home DS0000002195.V370040.R01.S.doc Version 5.2 Page 14 Relatives’ comments about activities included, ‘My relative plays draught and dominoes with the other residents’, ‘My relative has made friends here’, and ‘My relative likes the entertainment, particularly the music.’ During the inspection visitors were seen being made welcome at Derbyshire Haven and encouraged to make themselves at home. One visitor told us, ‘It’s always a pleasure to come here. Everyone’s so friendly and kind.’ Standard 14 – please see ‘Health and Personal Care’. On the day of inspection a new cook had just started work in the home. Lunch was served and consisted of cottage pie or liver and onions, with potatoes, parsnips, and green beans. Dessert was Eve’s pudding or stewed apple. The food appeared wholesome and appetising. Residents have a choice at every meal and their likes and dislike are posted on the wall in the kitchen so the cook is aware of them. One resident told us, ‘The food is marvellous. It’s nice to come down to breakfast and be given a choice of six cereals!’ A relative said, ‘There’s good variety of food and my relative is always full. It always looks lovely – when I see it I think, “I’d like to eat that!”’ Derbyshire Haven Care Home DS0000002195.V370040.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): Quality in this outcome area is good. Residents and their representatives are encouraged to talk to staff about any concerns they might have. Staff know how to safeguard residents. This judgement has been made using available evidence including a visit to this service. (Standards 16 and 18 were inspected.) EVIDENCE: All the residents and relatives we spoke to said they would have no hesitation in going to a member of staff if they were unhappy about anything. One resident told us, ‘If I wasn’t happy I’d tell the staff, the Deputy, or the Manager.’ The home’s complaints procedure is displayed in the entrance hall for those who want to refer to it. The Manager told she encourages residents to speak out if they have a complaint. She does this by having informal meetings with them and writing down their views, concerns, and comments. Records showed that any concerns are dealt with promptly. There have been no complaints about Derbyshire Haven since the last inspection. Staff have been trained in safeguarding adults. They are also given a booklet on safeguarding which they sign to say they have read. The training and information they have received will help to ensure they know what to do if they have concerns about how a resident is being treated. Derbyshire Haven Care Home DS0000002195.V370040.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Residents live in an environment that is safe, comfortable, and well maintained. This judgement has been made using available evidence including a visit to this service. (Standards 19 and 26 were inspected.) EVIDENCE: Devonshire Haven provides homely and comfortable accommodation to its residents. The entrance is welcoming, with information about the home’s history on the walls and a picture of its benefactor. In the lobby there are two displays of photographs, one of all the residents and one of all the staff. This makes it easier to work out ‘who’s who’ when you visit the home. Downstairs there is a large lounge with a range of different seating areas so residents can choose where to sit and with whom. Next door is the dining room where residents sit in groups of four at mealtimes. The bedrooms are spacious and most have room for both a living and sleeping area. One resident told us, ‘My room is excellent and I’m getting it into a state where I can call it mine.’ All bedrooms have ensuite facilities, including showers (with fitted shower Derbyshire Haven Care Home DS0000002195.V370040.R01.S.doc Version 5.2 Page 17 seats), and there is also a communal bathroom for those who prefer a bath to a shower. The home has its own cat, Lucy, who came as a stray. She is popular with the residents who like to stroke her and let her sit on their laps. Lucy is referred to in the home’s brochure so anyone thinking of coming to Devonshire Haven knows in advance that a cat lives there too. Since the last inspection new carpets have been fitted in corridors, bedrooms have been redecorated, and a new first floor ensuite bedroom created. However, further improvements are needed: • The external window frames are chipped with peeling paintwork and give a poor first impression of the home. These should be made good to bring the exterior of the home up to the standard of the interior. A number of residents said they were unable to watch television in their bedrooms as the poor reception distorted the picture and sound. This matter should be investigated, and a solution found, as for some residents television is an important source of entertainment. Most bedroom doors have reinforced glass inserts, which makes them appear institutional. Consideration should be given to eventually replacing these doors, or covering the glass with a curtain or similar. • • These should be discussed and consideration given to including them in any future improvement plan for the premises. Since the last inspection the home’s rear courtyard has been completely redesigned. The work was funded with a ‘Dignity in Care’ grant. The courtyard, which is secure and secluded, now features a fountain, a raised flowerbed (to make it easier for wheelchair users to see and smell the flowers), and a seating area. All areas inspected were immaculately clean and tidy. A relative told us, ‘This home always look lovely and is clean from top to bottom.’ Particular care is taken with the laundry. Each resident has their own wash basket in their room and their washing is done separately once a week. The Manager told us, ‘I don’t like the idea of putting all the residents’ washing in together. If we do a separate load for each resident the risk of cross contamination is reduced and the laundry doesn’t get mixed up.’ Derbyshire Haven Care Home DS0000002195.V370040.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. An established staff team meets residents’ needs. Relationships between staff and residents are warm and caring. This judgement has been made using available evidence including a visit to this service. (Standards 27, 28, 29, and 30 were inspected.) EVIDENCE: The staff we met were friendly and helpful. We saw they got on well with the people who live in the home. All the residents and relatives we talked to praised the staff team. One resident said, ‘The staff are very respectful and we have a good laugh with them too’, and another commented, ‘The staff will do anything you ask.’ A relative told us, ‘The staff are brilliant and have a good rapport with my relative.’ We looked at the rota, and talked to the people who live and work at Devonshire Haven, and found that the home is well staffed. There are two carers and the Manager on duty during the day and two carers at night. A cook and a cleaner are also employed. The Manager told us that one of the carers is usually based in the lounge. She said, ‘This is to supervise residents and provide them with activities. It is also to prevent them from falling, as she can persuade residents not to get up until staff are there to help them. Since we have had a carer in the lounge the number of falls in the home has dropped dramatically.’ Following a requirement made at the last inspection, recruitment procedures have been improved. All new staff are subject to CRB and POVA First checks Derbyshire Haven Care Home DS0000002195.V370040.R01.S.doc Version 5.2 Page 19 and references are obtained. Records were examined and showed that no one is allowed to start work in the home until all the necessary background checks have been done. This will help to ensure residents are safeguarded. Staff receive good training opportunities including a comprehensive induction, NVQs (National Vocational Qualifications), and short courses. Since the last inspection staff have attended courses on Safeguarding and the Mental Capacity Act. There is also a programme of staff appraisal and supervision in place. The training and support provided helps to ensure staff have the knowledge and skills they need to carry out their work. Derbyshire Haven Care Home DS0000002195.V370040.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Residents live in a home that is safe and well managed. This judgement has been made using available evidence including a visit to this service. (Standards 31, 33, 35, and 38 were inspected.) EVIDENCE: The Manager is well qualified and experienced. She has the Registered Managers Award, a recognised qualification for people who run care homes. In discussion she was knowledgeable about all the residents who live in the home and how best to meet their needs. One of the residents told us, ‘The Manager is very nice – she is always there for me, asking how I am, and she looks after her staff too.’ A Board of Trustees oversees the running of the home. They carry out Regulation 26 visits (formal visits required by law) every month and complete a report on what they have seen. This helps to ensure the Manager and staff are properly supported and providing a good quality service to the residents. Derbyshire Haven Care Home DS0000002195.V370040.R01.S.doc Version 5.2 Page 21 Since the last inspection the Manager has introduced a record book to collect residents’ views on the home. She has regular informal discussions with the residents, both as a group and on a one-to-one basis, and writes down any comments or suggestions they have. Records were examined and we saw that changes had been made as a result of what residents had said. For example, residents had asked for rabbit stew and this had been provided. Care plans had also been discussed and residents involved in the design of the new courtyard area. This helps to ensure residents have a say in the running of the home. Residents look after their own money or their relatives look after it for them. The Manager will look after small amounts of money for residents on request, for example if they want cash for hairdressing or chiropody. Appropriate financial records are kept when this happens, which show that residents’ money is being properly looked after. The Manager confirmed that appropriate checks and maintenance is carried out to help to ensure the home is safe for residents and staff. Since the last inspection the reporting of Regulation 37s has improved. Records showed that all untoward incidents, for example falls, are being reported to CSCI as required. Derbyshire Haven Care Home DS0000002195.V370040.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 4 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 Derbyshire Haven Care Home DS0000002195.V370040.R01.S.doc Version 5.2 Page 23 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. 1 Standard OP7 Regulation 15(1) Requirement Care plans must be put in place for any resident who is challenging. This will help to ensure that staff know what to do should an incident occur. Timescale for action 05/10/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP19 Good Practice Recommendations The areas of the home in need of attention (identified in the Environment section of this report) should be discussed and consideration given to including them in any future improvement plan for the premises. Derbyshire Haven Care Home DS0000002195.V370040.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Derbyshire Haven Care Home DS0000002195.V370040.R01.S.doc Version 5.2 Page 25 - 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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