Care Home: Haldon View

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What the care home does well What has improved since the last inspection? There is now evidence on file that satisfactory CRB (Criminal Records Bureau) checks have been obtained for all staff. Staffing is more flexible and the home is looking to improve this further so that more activities and outings can take place. An increase in funding that has recently been provided will also help in this area. A trampoline has been purchased that provides more outdoor activity for people and staff and representatives commented that everyone really enjoys using it. What the care home could do better: No requirements were made at this visit. However, the home needs to ensure the confidentiality of people`s information by ensuring no individual`s personal information is recorded in the staff communication book. The home should also explore ways of improving the communication with representatives especially with regard to letting them no about changes in staff. CARE HOME ADULTS 18-65 Haldon View 1 Beech Avenue Pennsylvania Exeter Devon EX4 6HE Lead Inspector Sue Dewis Key Unannounced Inspection 2nd November 2007 12:30 Haldon View DS0000039152.V349257.R01.S.doc Version 5.2 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 Haldon View DS0000039152.V349257.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 Adults 18-65. 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. Haldon View DS0000039152.V349257.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Haldon View Address 1 Beech Avenue Pennsylvania Exeter Devon EX4 6HE 01392 411229 01392 421317 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) http/www.devon.gov.uk Devon County Council Mr Nigel Frank Seal Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Haldon View DS0000039152.V349257.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Age Group - 18 - 65 years Date of last inspection 15th January 2007 Brief Description of the Service: Haldon View is a large detached house set in its own lovely grounds in a residential area of Exeter. It is on a bus route into the city and from the outside has nothing to distinguish it as a residential home. The home is owned by Devon County Council and offers evenings and weekend respite care for younger adults with learning disabilities between the age of 18 to 65 yrs. All bedrooms are for single occupancy only. Service users are individually assessed in order to determine their fees, but fees generally average £12 per night. General information about fees and fair terms of contracts can be accessed from the Office of Fair Trading web site at http:/www.oft.gov.uk . Copies of the CSCI reports for the home are available from the office. Haldon View DS0000039152.V349257.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over five hours, one day at the beginning of November 2007. The home had been notified that an inspection would take place within three months and had returned a completed AQAA (Annual Quality Assurance Assessment), that shows how the home has managed the quality of the service provided over the previous year. It also confirms the dates of maintenance of equipment and what policies and procedures are place. Information from this document was used to write this report. During the inspection 3 people were case tracked. This involves looking at peoples’ individual plans of care, and speaking with the person and staff who care for them. This enables the Commission to better understand the experience of everyone living at the home. As part of the inspection process CSCI likes to ask as many people as possible for their opinion on how the home is run. We sent questionnaires out to the representatives of 15 people who use the service and 17 staff. At the time of writing the report, responses had been received X representatives and X staff. Their comments and views have been included in this report and helped us to make a judgement about the service provided. During the inspection no-one staying at the home was spoken with individually but several were spoken with in a group setting and as they arrived for their stay at the home, as well as observing staff and those staying at the home throughout the visit. We also spoke with 2 staff and the manager in private. A tour of the building was made and a sample of records was looked at, including medications, care plans, the fire log book and staff files Some people staying at the home have limited verbal communication skills, and as we are not skilled in their other methods of communication it was difficult for us to have any meaningful communication with them. However, the interaction between those staying at the home and those who care for them was closely observed. Haldon View DS0000039152.V349257.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? There is now evidence on file that satisfactory CRB (Criminal Records Bureau) checks have been obtained for all staff. Staffing is more flexible and the home is looking to improve this further so that more activities and outings can take place. An increase in funding that has recently been provided will also help in this area. A trampoline has been purchased that provides more outdoor activity for people and staff and representatives commented that everyone really enjoys using it. Haldon View DS0000039152.V349257.R01.S.doc Version 5.2 Page 7 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. Haldon View DS0000039152.V349257.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Haldon View DS0000039152.V349257.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a good assessment and admission process in place, which means that people thinking of moving into the home can be sure that their needs will be met. EVIDENCE: Brief details of people wanting to use the service are initially obtained by the home from the care management team over the phone. The home then invites people and their family to visit the home for a look around and to discuss any concerns they may have. If they wish to proceed, they are given a blank copy of a care plan for them to complete. This is so that the home has as much information as possible about the prospective service user. If the placement is approved by the care management team, and the home feels they can meet the needs of the person wishing to use the service then a service contract is issued. The contract is usually signed by the person’s representative. Haldon View DS0000039152.V349257.R01.S.doc Version 5.2 Page 10 The home has a small brochure that is given to people that is user friendly and describes the service using symbols. The manager is planning to update this and the Statement of Purpose for the home to include changes to the service. People have at least one ‘Tea-visit’ at the home to meet staff and other people using the service, before a formal placement is made. Families book placements (usually six months in advance) direct with the home, the number of placements per year having been approved by the care manager. One representative indicated via a comment card that they felt having to book six months in advance did not allow them to be flexible. The manager told us that the home was always prepared to be flexible, though this could be difficult if all the places were already booked. On the day of the visit an emergency placement was made, the home had obtained basic information to ensure the needs of the person could be met, and would be completing a full assessment during their stay to ensure they could continue to meet their needs. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in order to improve the service the home intends to update the Statement of Purpose and brochure for the home to reflect new developments at the unit. Also to update some details in the service contracts. Haldon View DS0000039152.V349257.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a clear care planning system in place, that provides the information that staff need in order to satisfactorily meet the day to day needs of individuals. However, better recording systems are needed to ensure confidentiality. Peoples’ choice is sought and acted upon where possible. EVIDENCE: People visit the home on a regular basis, with the length of stay and frequency varying according to their assessed needs. Some visit one night each week, and others for a week every few months. This regular programme has enabled staff to build up information on individuals and to get to know them and their needs very well. Haldon View DS0000039152.V349257.R01.S.doc Version 5.2 Page 12 Three people’s care plans were inspected. All three contained good information and detail on the needs of the individual and how staff should meet these needs. The plans also give details of emergency contacts, allergies, sleeping pattern, reasons for using the service, likes and dislikes, medications, usual discharge/admission procedure and a brief profile of the service user, including their behaviour/disposition and their communication skills. For example one plan indicated that that person communicates through actions, that is they will show staff or take staff to what they need. Another plan indicated that anxiety needed to be managed by occupying the person otherwise the anxiety may develop into disruptive behaviour. The manager told us that the care plans designed to be as individual as possible allowing them to tailor the service around the individual. The plans also gave good details of how individuals like to spend their time at the home. As service users do not live permanently at the home staff rely on good communication between themselves and carers to ensure any changes in needs are passed on. There were good detailed and useful recordings on each file looked at. However, one representative indicated on a comment card that although “on the whole we are kept informed” they also felt that “Information is not always forthcoming and when it is eventually to hand it is late”. There is a communication book that staff use to pass on information to each other about different people staying at the home. This means that anyone wishing to see information written about them, would also be able to anything written about other people. This is not acceptable and is in contravention of the Data protection Act. Communication abilities vary substantially across the people who use the service, with some being very able and others much less so, and we were unable to communicate with all those at the home at the time of the visit. However, one person accompanied us on our tour of the building and was able to us the room they were using. Staff were observed communicating very well with people, using verbal and non-verbal communication. Individuals were wandering freely around the home, smiling and laughing and they appeared comfortable and relaxed in the presence of the staff. Some people have a ‘box’ that is kept at the home and contains personal items. This enables staff to be able to put these items into the room the individual will be staying in to make it feel more welcoming and homely. There is a laundry drying area within the home that contains very hot pipes, which residents have limited access to, risk assessments have been completed and a gate has been fitted to the doorway to limit access further. (see also Standard 42). Haldon View DS0000039152.V349257.R01.S.doc Version 5.2 Page 13 The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in order to improve the service the home intends to continue to regularly review and consult with people who use the service and their representatives. Haldon View DS0000039152.V349257.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from being offered a variety of activities and opportunities. Meals are nutritious and balanced and offer a healthy and varied diet for everyone. Individuals’ rights are respected and recognised within the home affording them as much independence as possible. EVIDENCE: Some of these standards are not entirely applicable as staff at the home are not the primary carers for people and limited time is spent in the home. Haldon View DS0000039152.V349257.R01.S.doc Version 5.2 Page 15 People usually continue to attend any day services they would normally attend when not at Haldon View. This means that the home has limited staffing available throughout the day in case of an emergency requiring the service user to be back at the home. However, on the day of the visit, some people were at the home due to their usual day services being closed for the week. There were two staff and the manager at the home during this time. There is a games room at the home, with a pool table and computer available for people to use if they wish. The home has recently acquired a trampoline and staff and the manager said it was one of the best things they had ever bought as everyone staying at the home loved using it. We were told that people are often quite tired when they get home from day services and often prefer just to watch TV or spend quiet time in their rooms. Concerns had previously been raised by representatives, via comment cards, that there were not suitable activities and outings provided. The manager told us that they had tried hard to ensure more activities and outings were offered. A new vehicle is being purchased so that more staff can drive it and more outings can take place. New grant money has been obtained to enable an increase in activities and the manager is currently drawing up a ‘menu of activities’ that will be available. At a recent staff meeting there was a review of everyone using the service to determine what they all like to do so their choice of activity can be included. When the emergency admission arrived at the home they were made welcome and helped to settle in. People only attend the home for short periods, and usually this is to allow their relatives a break. Therefore, there are limited visits from families when people are at the home. One representative commented via a survey form “We tend to go away when we have the chance of a break. An emergency situation would therefore be the only reason I would expect contact”. There is a menu drawn up, with changes made as necessary, depending which service users are at the home. Meals provided during the visit were balanced and nutritious. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in order to improve the service the home intends to improve the social and leisure activities on offer through extra funding and the purchase of a new vehicle. Haldon View DS0000039152.V349257.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff have a good understanding of the personal support needs of individuals, and people benefit from the positive relationships they have with staff. To ensure the safety of individuals, all medicines are generally stored securely, administered appropriately, and good records maintained. EVIDENCE: Care plans contain detailed instructions on the type of support needed and how it should be offered to each individual. Staff that were spoken with displayed a good knowledge of the individual personal care needs of the different people visiting the home. Throughout the visit staff were seen to offer support in a polite and discreet manner. It was clear from observations that good relationships have been formed between people living and working at the home. Haldon View DS0000039152.V349257.R01.S.doc Version 5.2 Page 17 One representative commented via a survey form “The care our daughter receives is of a very high standard”. The home is not normally responsible for initiating health care services, unless there is an emergency. However, they do monitor and manage any ongoing health issues, for example incontinence and epilepsy. Detailed records of any interventions are kept and staff have received appropriate training in dealing with such issues. People’s medications are usually obtained by their families and the individual generally either brings in the exact quantity for their stay, or all of their medication. However, medication is held at the home for some service users. When medication is received at the home it is counted, and again when it is taken out of the home. There are good policies and procedures relating to the administration of medicines. There have been some minor mistakes in handling medicines in the past and this has resulted in a further tightening of the procedures, ensuring that risk of further mistakes is minimised. All staff who administer medications have been appropriately trained and updated as necessary and records show weekly audits of medications and two staff signatures for all medicines that are administered. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in order to improve the service the home intends to review all records and improve procedures to ensure written instructions on the care needed are provided. Haldon View DS0000039152.V349257.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are dealt with appropriately and individuals are protected by staff who are able to recognise abuse and know their duty to report poor practice. EVIDENCE: The home uses the Devon County Council Complaints procedure. A new ‘user friendly’ document has been produced using symbols. It asks people to ‘Say what you like’, ‘Say what you don’t like’ and ‘Say what you think’. The manager told us that there are occasional concerns raised that are dealt with straight away. However, one representative commented via a survey form “Although a response has been made regarding any concerns (usually a minor problem) sometimes these concerns have to raised again at a later date”. The general manager for the ‘Short Breaks’ service holds regular ‘surgeries’ at the Nichols Centre and people are able to go direct to her with any concerns they may have. No complaints have been received by the Commission since the last inspection. Staff have received training in POVA (Protection of Vulnerable Adults) issues, although no-one has had training on the new Mental Capacity Act. The two staff that were spoken with were able to give good descriptions of differing Haldon View DS0000039152.V349257.R01.S.doc Version 5.2 Page 19 types of abuse and of the procedure they would follow should abuse be suspected. This included contacting outside agencies if necessary. Only small amounts of monies are held by the home on behalf of people during their stay and these monies are managed appropriately. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in order to improve the service the home intends to laminate the complaints procedure so that it can be displayed in the hallway, and to ensure all staff receive training on the new Mental Capacity Act. Haldon View DS0000039152.V349257.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a good standard of décor throughout and ensures that individuals live in a safe, homely and comfortable environment. EVIDENCE: The home is generally comfortable and well maintained. The furnishings and fittings are of a good standard and a domestic nature. Much effort is made to minimise the short-stay ‘hotel’ feel and to maximise the homeliness so that people will feel welcome when staying there. Some new furniture and televisions have recently been purchased, new laminate flooring has been fitted to the hallway and some new carpets have been fitted around the home. However, the entrance hall and some bedrooms are still in need of redecoration. Haldon View DS0000039152.V349257.R01.S.doc Version 5.2 Page 21 The home tries to provide the same room for people each time they visit the home. A small box of personal items is kept for some individuals and these are put into their rooms before they arrive. The rooms contain TVs and are generally comfortably furnished and decorated. There is a comfortable and well maintained lounge/dining area and several other communal areas around the home that people can use if they wish. There are aids and adaptations around the home such as a stairlift, grab rails, assisted baths, and a walk-in shower. A call-bell system has recently been installed that staff can use in an emergency situation and alerts them when outside doors have been opened. The dishwasher and a freezer are sited in the laundry, which could lead to cross infection. However, the Food Safety department of Exeter City Council feel that as long as clean/dirty tasks were separated by time, and no food was prepared in that area, they would not take any action. Therefore, no recommendations are made regarding this area. Staff have received training in Basic Food Hygiene and Infection Control. Liquid soap and paper towels are available in all toilets and disposable gloves and aprons are freely available which helps minimise the risk of cross infection. On the day of the visit the home was clean throughout and there were no unpleasant smells. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in order to improve the service the home intends to redecorate some rooms and to continue to replace furnishings where necessary. Haldon View DS0000039152.V349257.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are well trained and are available in sufficient numbers to meet the needs of the individuals living there. The procedures for the recruitment of staff are robust and offer protection to individuals. EVIDENCE: There are usually two staff on duty while service people arriving at the home, then three staff from 5pm till 10pm. We discussed the staffing levels with the manager, who feels that they are adequate for the numbers of people currently using the home. Some individuals need more support than others and these are counted as two people when they are staying at the home, so that staff have enough time to spend with everyone. However, some comments from representatives via comment cards indicated that they felt there was a need for more staff to enable more outings and outside activities and to ensure good Haldon View DS0000039152.V349257.R01.S.doc Version 5.2 Page 23 supervision of individuals at all times. The manager said that these were priorities of the home at all times and felt that this was the case for the vast majority of the time. The staff that we spoke with, had worked at the home for several years and had received training in many aspects of care. All staff receive training that helps them meet the service users’ needs effectively and safely. For example, most staff have received training in epilepsy, Protection of Vulnerable Adults, continence, NVQ (National Vocational Qualification - A formal care qualification) and much more, including health & safety training, such as fire awareness, food & hygiene and so on. This means residents benefit from a well-trained team of staff that are able to meets their needs effectively. A total of 11 staff working at the home currently have an NVQ qualification of level 2 or above with another 2 staff working towards the qualification. This meets the standard for the home to have more than 50 of staff with this qualification. Induction and foundation training is in line with the Learning Disability Award Framework (LDAF). Staff spoken with and others on survey forms said that they felt the home provided a safe and comfortable environment for the people that visit. Three staff files were inspected. All contained the required information, including satisfactory CRB (Criminal Records Bureau) checks, application forms, proof of identity and two references. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in order to improve the service the home intends to not become complacent and to continue to review and improve the service. Haldon View DS0000039152.V349257.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed resulting in practices that generally promote and safeguard the health, safety and welfare of people living and working there. The systems for consultation with people living, working and visiting the home are good, with a variety of evidence that indicates that their views are both sought and acted upon. EVIDENCE: Nigel Seal has been registered as manager of the home for two years. He had worked at the home for some years prior to this as assistant manager and has many years experience of working with people with a learning disability. Staff Haldon View DS0000039152.V349257.R01.S.doc Version 5.2 Page 25 commented via survey forms that “I am able to meet and discuss any issues with my line manager – I feel totally supported” and “We have a good and caring manager”. There are regular quality assurance visits and reports made by the Responsible Individual for the home. The home has sent out questionnaires to representatives and people using the service are regularly asked for their views. Feedback is also sought verbally from care managers. However, one issue identified in comment cards we received was that representatives thought communication could be improved. In particular one representative felt they would like to be kept informed about changes in staff and wanted to be introduced to new staff. So that they knew who was caring for their relative. The manager said that he would look at ways to make sure this happened in the future. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit provided evidence that Haldon View complies with health and safety legislation in relation to maintenance of equipment, storage of hazardous substances, health and safety checks and risk assessments. The fire logbook, record of fire safety training and accident and incident records were found to be accurate and up to date. So that the risk of burning from hot surfaces is minimised, all radiators within the home are covered, and people’s access to the very hot pipes in the drying area of the laundry has been restricted (see also Standard 9). All windows above ground floor level are fitted with restrictors, in order to minimise the risk of anyone falling from these windows. A new risk assessment procedure is being introduced and all risks to individuals and the general environment are currently being reassessed. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in order to improve the service the home intends to deliver a more flexible service, to continue to consult with all involved with the service, to increase activities and staffing levels and to continue to improve the facilities. Haldon View DS0000039152.V349257.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 2 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Haldon View DS0000039152.V349257.R01.S.doc Version 5.2 Page 27 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. 1. 2. Refer to Standard YA10 YA15 Good Practice Recommendations You should ensure recordings made in the staff communication book are confidential. You should explore ways to improve communication with people’s representatives. Haldon View DS0000039152.V349257.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Haldon View DS0000039152.V349257.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. 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