Care Home: Henderson and Harvard

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What the care home does well Henderson and Harvard provides a service that values the individuality of people who live there. Interactions between staff and people in the home are good. Staff are able to provide support for people in a way that meets their needs and wishes. Staff ensure the personal and healthcare needs of people living in the home are met and relevant healthcare professionals are consulted where appropriate. Henderson and Harvard provides a comfortable environment for people with bedrooms that reflect individual tastes. There are aids and adaptations to help people maintain their independence. Visitors are made welcome and people are encouraged to maintain contact with families and friends. What has improved since the last inspection? Some areas throughout the home have been redecorated and in general the premises are fresh and clean. There has been refurbishment of the shower room and it is now a more pleasant place for people living there. What the care home could do better: They should continue to make improvements to the environment, particularly around providing a separate quiet lounge so that people living in the home are able to meet with visitors somewhere private that is separate from their individual bedrooms. CARE HOME ADULTS 18-65 Henderson and Harvard Kelvedon Road Tiptree Colchester Essex CO5 0LJ Lead Inspector Ray Finney Unannounced Inspection 23rd November 2007 10:00 Henderson and Harvard DS0000017845.V355435.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 Henderson and Harvard DS0000017845.V355435.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. Henderson and Harvard DS0000017845.V355435.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Henderson and Harvard Address Kelvedon Road Tiptree Colchester Essex CO5 0LJ 01621 819235 01621 819354 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) www.scope.org.uk SCOPE Care Home 8 Category(ies) of Learning disability (8), Learning disability over registration, with number 65 years of age (1), Physical disability (8), of places Physical disability over 65 years of age (1) Henderson and Harvard DS0000017845.V355435.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability who may also have a physical disability (not to exceed 8 persons) One person, aged 65 years and over, who requires care by reason of a learning disability who may also have a physical disability, whose name was made known to the Commission in March 2003 30th November 2006 2. Date of last inspection Brief Description of the Service: Henderson and Harvard consists of two converted semi-detached bungalows located in the town of Tiptree. Each bungalow provides accommodation for four people in single bedrooms. The home is adapted to meet the needs of people with physical disabilities. All local facilities and amenities are within easy access. There is parking to the front and the side of the bungalows. People living in Henderson and Harvard benefit from pleasant, well-maintained gardens and patio areas. The space between the two bungalows has been joined and converted to provide a shared laundry area. The home charges between £780.54 and £1328.96 a week for the service they provide. People pay extra for personal items such as toiletries, clothes, hairdressing and admission fees to leisure and recreational activities of their choice; the cost for these is normal retail prices. This information was given to us in November 2007. Information about the service can be obtained by contacting the home. Inspection reports are available from the home and from the CSCI website www.csci.org.uk Henderson and Harvard DS0000017845.V355435.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A range of evidence was looked at when compiling this report. Documentary evidence was examined, such as menus, staff rotas, care plans and staff files. The acting manager completed an Annual Quality Assurance Assessment with information about the home. Throughout the report this document will be referred to as the ‘AQAA’. We sent surveys out to people living in the home, relatives, health & social care professionals and members of staff and a total of 12 were completed and returned. All questionnaires contained positive responses about the service provided at Henderson and Harvard. A visit to the home took place on 23rd November 2007 and included a tour of the premises, discussions with people in the home, the acting manager and members of staff. Observations of how members of staff interact and communicate with people living there have also been taken into account. On the day of the inspector’s visit the atmosphere in the home was relaxed and the inspector was given every assistance from assistance from the acting manager, the administrator and members of staff. What the service does well: What has improved since the last inspection? Some areas throughout the home have been redecorated and in general the premises are fresh and clean. There has been refurbishment of the shower room and it is now a more pleasant place for people living there. Henderson and Harvard DS0000017845.V355435.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. Henderson and Harvard DS0000017845.V355435.R01.S.doc Version 5.2 Page 7 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 Henderson and Harvard DS0000017845.V355435.R01.S.doc Version 5.2 Page 8 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. People choosing to live at Henderson and Harvard receive sufficient information about the home and may be confident their needs will be assessed before admission. EVIDENCE: The AQAA states that they have a Service User Guide in place that can be provided in different formats such as large print and symbols. The guide gives information that will help people wishing to move into the service make an informed choice as to whether it is the right place for them. There is also a Statement of Purpose available that can also be produced in different formats. On a tour of the premises, the updated Service User Guide was prominently displayed. The document has been produced in symbol format, laminated and put on the notice board. There have been no new admissions to the home recently but there are two vacancies. The AQAA states that they would carry out a pre-assessment for anyone wishing to move in to Henderson and Harvard bungalows. An in-depth care profile is completed detailing the level of support the individual needs and a care plan is produced using this information. Henderson and Harvard DS0000017845.V355435.R01.S.doc Version 5.2 Page 9 A discussion with the acting manager confirmed that they use SCOPE’s assessment process. This is a robust process that involves carrying out a preadmission assessment, which is comprehensive and covers a wide range of areas of need. A sample of three individual files examined all contain comprehensive assessments that are reviewed and form the basis for care plans. People moving into Henderson and Harvard can be confident that their needs will be thoroughly assessed to make sure the service will be able to meet their needs. As previously reported, anyone wishing to move in is encouraged to come for an overnight trial stay. The AQAA states that a twelve week trial placement is then offered, during which time the person will be supported by a nominated key worker to help them settle in. After the trial period, there will be a review with the person and any other relevant parties such as relatives. At this review a decision is made as to whether the placement is suitable and the person wishes to stay. A sample of indicvidual records examined all contain a service agreement with details of the terms and conditions of the service. This ensures that everyone is clear about their rights and responsibilities. Henderson and Harvard DS0000017845.V355435.R01.S.doc Version 5.2 Page 10 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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in Henderson and Harvard benefit from having good care plans that recognise and value people’s individuality. They are supported to make decisions about their lives and take part in the running of the home. EVIDENCE: The AQAA states that care plans are all individual and tailored to meet the needs of each person. People living in the home are are actively involved in setting up, monitoring and reviewing their own care plans along with other interested parties. A sample of three care plans was examined; they are all individual and wellmaintained. There is evidence of people’s interests reflected throughout the care plans. Each section is clearly separated with laminated dividers which contain pictures of the person’s interests or which are decorated individually. There is evidence of good use of photographs throughout to demonstrate the way people like to have things done. Care plans are written from the Henderson and Harvard DS0000017845.V355435.R01.S.doc Version 5.2 Page 11 viewpoint of the individual and clearly document both what their needs are and they way they prefer to have these needs met. A wide range of needs are addressed in the care plans examined, including mobility/transfers, domestic support needs, daily living skills, finances, bathing/hair care etc, continence, mealtimes/diet, bedtime/night-time needs, self-image/appearance. People living in Henderson and Harvard can be confident that staff have sufficient information to support them appropriately and in the way that they wish. The AQAA states that care plans are reviewed at least every six months and amended when people’s needs change; there is an annual review meetings for each individual during which care plans are reviewed. Records examined confirm that care plans are reviewed, so people can be assured that information about their needs is up to date. A self-audit identified the need for further training on developing care plans and recording information. This has been included in the coming year’s training schedule for all staff. One person decided to have photographs showing the way they did not want to be supported and the way they prefer to be supported so that all staff are aware of their preferences. This gives clear guidelines to staff around how to do things the way the person wishes. Care plans examined clearly detail the way people want to be given choice. One person said they sometimes like to wear a protective apron at mealtimes but sometimes don’t and want to be given the choice. Similarly someone wants to be given choices around the type of cutlery used for particular foods. The AQAA states that service user meetings are held on a regular basis, which ensures individual needs and wishes are listened to and acted upon. Minutes of these meetings confirm that people raise issues and they are acted upon. Records examined confirm that there are risk assessments in place. At present they use specific risk assessment forms that clearly identify the area of risk, those who may be at risk, what the risk is, existing precautions taken and any additional precautions taken. Risk assessments include scalds/burns from hot food, manual handling and transfers such as from bed to chair or chair to bath. There was a discussion with the acting manager around a new comprehensive risk assessment being developed called a ‘Risk Assessment and Management Profile. People living in Henderson and Harvard can be confident that there is a good process in place to help minimise risk without being restricted. This ensures people are able to make informed choices about what are acceptable risks. Henderson and Harvard DS0000017845.V355435.R01.S.doc Version 5.2 Page 12 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, 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 living in Henderson and Harvard have opportunities to take part in activities that are appropriate to their needs. They are supported to access facilities in the local community and are able to build and maintain relationships. People have a varied diet that they enjoy. EVIDENCE: All individual records examined contain ample evidence of activities including college courses, which three people attend. The acting manager and administrator provided information about the specific courses that people are taking part in. One person is doing a beauty therapy course. People also attend church and bible study group. A survey completed by a person living in the home said they would “like to go out more in the evenings”. The AQAA states that individual choice with regards to accessing activities is an integral part of the service they provide. During service user meetings Henderson and Harvard DS0000017845.V355435.R01.S.doc Version 5.2 Page 13 discussions take place and suggestions are put forward about what type of activities are available and who would like to attend. There are two vehicles available that are fully accessible so that people can be supported to access activities out in the community. Overall, people living in Hendeson and Harvard can be confident that they will be supported to have a lifestyle that they enjoy. Records examined confirm that people using the service are supported to maintain personal relationships. A survey completed by a relative states that they “phone at least twice a week and our relative comes home for the weekend every few weeks”. People spoken with on the day of the inspection were able to confirm that they keep in touch with families and friends. People spoken with were able to demonstrate that they understand their rights and are able to make their wishes known. One person with limited verbal communication uses email to communicate with admin staff and management. Another person is very vocal about making wishes and needs known and ensures that staff are aware of their opinions. The manager said that it is in the pipeline to extend the empowerment training that was piloted in two other SCOPE homes locally. Overall, people living in this service can be confident that they will be supported to understand their rights and responsibilities and challenge the service they receive. No one living at Henderson and Harvard currently has specialist feeding needs. However, the staff and management are conscientious around ensuring people have diets that are appropriate for their needs. Records examined show that there is a variety of healthy, nutritious food available and people spoken with say that they enjoy the food. Henderson and Harvard DS0000017845.V355435.R01.S.doc Version 5.2 Page 14 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. People using the service receive personal and healthcare support that meets their needs. Henderson and Harvard has systems in place to ensure the safe administration of medication and the protection of people living there. EVIDENCE: The AQAA states that the service will continue to develop individual care plans with people, including choice about the ways in which they are supported. Care plans examined confirm that personal care is well documented. One person has worked with staff to take photographs of the way they like their clothes arranged around their wheelchair straps and the way they don’t like it so that all staff are clear about the person’s wishes. Observations on the day confirm that people’s dignity is maintained and staff are sensitive and discrete when helping people with personal needs. As at last inspection, records confirm that comprehensive health assessments are in place including physiotherapy, manual handling needs and assessments relating to specific medical conditions such as epilepsy and deafness. Henderson and Harvard DS0000017845.V355435.R01.S.doc Version 5.2 Page 15 Care plans examined contain good recording of people’s healthcare needs. The plans contain a ‘hospital assessment’ that has been put in place so that, should an individual need to be admitted to hospital, all relevant information is ready to go with them. All those living in Henderson and Harvard are registered with local General Practitioners and are supported to access healthcare facilities as and when required. Care plans contain health recording sheets, weight charts and evidence that people visit health care professionals such as the dentist or G.P. when necessary. Records examined contain evidence of medical appointments including chiropodist, dentist, optician, physiotherapist, and sensory nurse. The AQAA states that individual care plans indentify health and care needs and how staff should meet these needs. A tour of the premises confirms that people have appropriate aids and adaptations to meet their needs including overhead tracking, electric hoists, assisted baths, electric wheelchairs and standing frames. Since the last inspection new overhead electric hoists have been installed. All these aids ensure people are able to be as independent as possible. The home operates a monitored dose system for the administration of medication. There are no controlled drugs in use in the home at the current time and no-one is able to self-medicate so all are supported by staff. As before, storage of medication was examined and found to be appropriate. A separate fridge is available for storage of medications requiring controlled temperature. Medicine Administration Record (MAR) sheets were examined. MAR sheets are correctly completed and contain pictures of service users to minimise the risk of giving the wrong medication. Care plans examined contain relevant information about prescribed medication. Staff files examined contain evidence of staff training around the administration of medication. People can be confident that there is a robust system in place to protect them and ensure they are supported appropriately with prescribed medication. Henderson and Harvard DS0000017845.V355435.R01.S.doc Version 5.2 Page 16 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. People who use the service have access to an effective and understandable complaints procedure that ensures they are listened to. There are procedures in place to protect the people who live there. EVIDENCE: There is a Complaints Resolution Procedure in place. The policy and procedure has been updated and a new log book for recording complaints is being introduced. Records examined confirm that the service takes complaints seriously and deals with them openly. People spoken with say they know what to do if they want to complain about something. SCOPE now employs a person who takes responsibility for issues around safeguarding people. The manager said this will support the robust procedures already in place. Records examined confirm staff have received Protection of Vulnerable Adults (POVA) training. A previous protection issue was discussed with the acting manager. Advocacy services and the adult protection team were alerted. The situation was dealt with appropriately and resolved to the satisfaction of the person raising the issue. The AQAA states that they plan to ensure staff receive POVA, whistle-blowing and complaints refresher training within this review period. This will ensure Henderson and Harvard DS0000017845.V355435.R01.S.doc Version 5.2 Page 17 that responsibilities around safeguarding issues are reinforced with the staff team and people are well protected. Henderson and Harvard DS0000017845.V355435.R01.S.doc Version 5.2 Page 18 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, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in Henderson and Harvard benefit from a comfortable environment that is well maintained and clean. There are adaptations and equipment in place to meet the needs of the people living there. EVIDENCE: The AQAA states that major refurbishment of the shower room area within both bungalows and redecoration of communal areas has taken place, taking people’s choice and preferences into account. A tour of the premises confirms that the communal areas are well decorated. The décor is homely and comfortable and people spoken with confirm that they like it. People’s bedrooms are all individually decorated to their personal taste. One person is having their room refurbished in a striking and sophisticated colour scheme. The person chose the colours to reflect their character and personality. This resident told the inspector that they are really enjoying Henderson and Harvard DS0000017845.V355435.R01.S.doc Version 5.2 Page 19 choosing things for the room. Another person is moving to a different room after Christmas and is also enjoying the process of choosing décor. The grounds outside are all accessible and well-laid out so that people can get around independently. On the day of the inspection visit people in the home were seen to enjoy accessing the gardens. Considerable work has been carried out including improving car parking facilities. A separate visitor’s room was planned within the Henderson bungalow to give people living in the home somewhere to meet with family and friends in private. These plans may now be reviewed and the possibility of providing an alternative area such as a conservatory is now being considered. Aids and adaptations throughout the two bungalows and grounds are well designed to meet the needs of people living there. Paths throughout the gardens are wide and safe for wheelchair users. Doors are fitted with automatic openers to assist people with physical needs. All bedrooms and bathing areas have electric overhead tracking and hoists. Adaptations to assist people with limited movement to use a computer are available. The range of equipment provided benefits people using the service by increasing their independence. A comment made in one of the completed surveys on what could be improved was “More hours allocated to maintenance”. The AQAA states that a domestic member of staff has been employed to maintain standards of health and hygiene. A tour of the premises confirmed that there is a good standard of cleanliness throughout the premises. The laundry area is also clean and well maintained. Records examined confirm that staff have received training around infection control. People living in the home can be reassured that they are protected by the good processes in place to prevent the spread of infection. Henderson and Harvard DS0000017845.V355435.R01.S.doc Version 5.2 Page 20 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, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in Henderson and Harvard benefit from a competent, well trained staff team who receive appropriate supervision. The recruitment procedure provides the safeguards that ensure appropriate staff are employed. EVIDENCE: The AQAA states that the service continues to work towards achieving 50 of support staff with a National Vocational Qualification (NVQ) award at level 2 or above. A senior support worker has completed the NVQ ‘A1 assessors award’ and will be able to support the staff who are working towards obtaining NVQ. Records show that out of a total of fourteen support staff, six have obtained NVQ at level 2 or above and nine are currently working on an award. A sample of personnel files examined confirm that some staff have finished an NVQ award. A survey completed by a relative commented, “Sometimes I feel that if only two staff are in attendance some things cannot be done because all the residents are totally dependent for all care”. On the day of the inspection staffing levels were observed to be good and people were going out for Henderson and Harvard DS0000017845.V355435.R01.S.doc Version 5.2 Page 21 activities. One person living in the home commented that staff “couldn’t be better”. A sample of three staff files was examined. Records are well maintained and all the necessary documentation is in place, including photographs, references, health declarations, proof of identity and Criminal Records Bureau (CRB) checks. People living at Henderson and Harvard are protected by a robust recruitment process that ensures rigorous checks are made before a person is employed. As previously reported, SCOPE provides an effective training programme to ensure all staff have the necessary skills. Records examined confirm that staff receive a range of training including Health & Safety, POVA refresher training, Food Hygiene, Infection Control and Care of Medicines. Training in ‘Makaton’ to assist people with communication difficulties is carried out. Specific training around health related issues is also given. A well trained staff team ensures that people living in the home receive appropriate support to meet their needs. Records examined confirm that staff supervisions are being carried out. Staff spoken with on the day of the inspection visit feel well supported. Staff who are well supervised and receive appropriate support from management perform better and this improves the service for people who live there. Henderson and Harvard DS0000017845.V355435.R01.S.doc Version 5.2 Page 22 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. Henderson and Harvard is competently managed and run in the best interests of the people who live there. The health and safety of individuals living and working in the home is promoted and protected. EVIDENCE: The AQAA states that a recent management restructure has resulted in there being no registered manager in Henderson and Harvard. The staff team are working hard to minimise the effect on people living in the home. The home is being ‘caretaker’ managed by the manager of another SCOPE service, who is local and knows Henderson and Harvard well. The AQAA states she will be overseeing, supporting and directing the staff team, until another service manager is appointed. Henderson and Harvard DS0000017845.V355435.R01.S.doc Version 5.2 Page 23 The manager explained that the recruitment process for a new manager has been carried out and someone has just been appointed who will be taking up the post soon. Credit must be given to the manager for the high standard of management in the interim period. As previously reported, SCOPE continues to have a robust Quality Assurance process in place. The AQAA states that there is an annual process of obtaining quality assurance feedback in place. Information from the last process has been collated, analysed and an action plan produced in response. Records examined confirm that an action plan was developed from the information received. There are records of meetings with people in the home where their opinions are sought. The manager confirmed that the views of people are an integral part of the service they provide. People spoken with who were able to express an opinion say that the management and staff listen to them. Overall people living in Henderson and Harvard can be confident that their opinions on the service are sought and acted upon. As at the last inspection, all Health & Safety records examined were found to be in good order and up to date. A sample of records was examined, which confirmed the information provided in the AQAA. There is evidence that Portable Appliance Testing was carried out recently, hoists, heating and fire equipment have also had recent maintenance checks. Records examined also confirm that staff have received infection control training and there are COSHH (Control of Substances Hazardous to Health) assessments in place. People living in the home are protected by the robust processes in place relating to health and safety. Henderson and Harvard DS0000017845.V355435.R01.S.doc Version 5.2 Page 24 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 3 29 4 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Henderson and Harvard DS0000017845.V355435.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA28 Good Practice Recommendations The manager should continue with the plan to provide people with a private area to meet with visitors, which is separate from their own private rooms. The manager should continue to support staff to achieve NVQ awards so that people benefit from a well trained staff team. 2. YA32 Henderson and Harvard DS0000017845.V355435.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Henderson and Harvard DS0000017845.V355435.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. Re-publishing this information is in breach of the terms of use of that website. 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