Inspection on 16/11/07 for Fair Haven

This inspection was carried out on 16th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fair Haven 29/06/06

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Fair Haven 54 Linden Avenue Clay Cross Chesterfield Derbyshire S45 9HE Lead Inspector Tony Barker Unannounced Inspection 16th November 2007 09:15 Fair Haven DS0000065893.V354453.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 Fair Haven DS0000065893.V354453.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. Fair Haven DS0000065893.V354453.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fair Haven Address 54 Linden Avenue Clay Cross Chesterfield Derbyshire S45 9HE 01246 862972 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) Enable Care & Home Support Limited Mrs Glenys Catherine Wood Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Fair Haven DS0000065893.V354453.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th July 2007 Brief Description of the Service: Fair Haven was registered in December 2005. Two residents and the staff transferred from Wood Street, Holmewood, which de-registered. The dormer bungalow accommodates three service users. It is situated in a quiet private residential area within 15 minutes walk of the shops and amenities. The bungalow has its own private garden where service users can sit. Accommodation consists of two bedrooms, a communal lounge, separate dining room/quiet room, kitchen, laundry and bathroom, on the ground floor. The first floor has a bedroom plus sleep over room and toilet. Fair Haven DS0000065893.V354453.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The time spent on this inspection was 8 hours and was a key unannounced inspection. All three female service users, the Manager and a home support worker were spoken to. The service users were observed working with and being cared for by staff. Records were inspected and there was a tour of the building. One service user was case tracked so as to determine the quality of service from their perspective. Survey forms were posted to the three service users – all were returned; to their relatives – two were returned; to four staff – all were returned; and one health professional which was returned. The information supplied in this way was analysed before the inspection and the outcomes included in the inspection process and reflected in this report. This inspection focussed on all the key standards and on the progress made towards achieving the requirements and recommendations made at the last inspection. The pre-inspection, Annual Quality Assurance Assessment (AQAA), questionnaire was reviewed prior to this inspection. The service’s fees were £307 per week as stated on the Service Users’ Guide. A copy of the last inspection report, from the Commission for Social Care Inspection (CSCI), is available to service users and visitors and is kept in the staff room. What the service does well: What has improved since the last inspection? Service users’ statement of terms and conditions had been adjusted to reflect the move to this Home from Wood Street. Quality assurance questionnaires had been sent to the relatives of all three service users. Fair Haven DS0000065893.V354453.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. Fair Haven DS0000065893.V354453.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 Fair Haven DS0000065893.V354453.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): 2&5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each service user had an individual contract, set out in an appropriate format, to provide them with sufficient information about the service and its cost. EVIDENCE: The three service users have lived in this Home since December 2005. A full assessment of their needs was made prior to their admission, as confirmed by detailed examination of care records at the previous inspection. Needs assessments were holistic and being reviewed annually. One member of staff who completed the postal survey felt that the service does well in “catering for service users’ needs physically, emotionally and spiritually”. Each service user had a contract and statement of terms and conditions, detailing the fees covered. These had been adjusted to reflect the move to this Home from Wood Street, as recommended at the previous inspection. Fair Haven DS0000065893.V354453.R01.S.doc Version 5.2 Page 9 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 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users had individual and up to date plans of care which demonstrated that their health, personal and social care need were being met. A ‘person centred’ approach was being taken to ensure that service users’ individual needs and wishes were focussed on. EVIDENCE: There was a good range of care plans, each with regular evaluation notes. Care plans were being formally reviewed twice a year – one of these being ‘inhouse’ and one with Social Services’ involvement. Service users were involved in all these reviews and their relatives were invited too. Additionally, there was a Care Plan Assessment Record comprising ‘Activities of Daily Living’. Service users’ social and emotional needs were recorded in the needs assessments though there were no recorded goals to address attainment of these needs. Each service user had a fully completed Personal Planning Book that was an excellent person centred document. It included sections such as ‘Important People in my Life’ and ‘Things that are important to me’. The section entitled ‘My Goals’ did include social and recreational goals. A further Fair Haven DS0000065893.V354453.R01.S.doc Version 5.2 Page 10 document called ‘My Action Plan’ had been designed to show how to follow up on ‘My Goals’ but had not been completed for any service user. There was plenty of evidence that service users were making decisions for themselves and were fully participating in the everyday functions of the service. One service user had chosen and bought an item of clothing on the day of this inspection and was clearly very proud of the purchase. The Manager stated that after a holiday visit to the Isle of Wight in July 2007 the service users chose to follow this with an overnight stay in Gateshead early in November. Individual preferences were being addressed regarding recreational pursuits. The service’s four-week rolling menu had been written by one of the service users. There was a range of recorded risk assessments and evidence that service users were being enabled and supported to take ‘responsible risks’. The home support worker spoken to, and the Manager, both mentioned one service user who walks into Clay Cross on her own. When this happens for the first time, after a break from this activity, she is discretely followed by staff who monitor her ability to negotiate roads safely. A recorded risk assessment was in place to address this activity. Fair Haven DS0000065893.V354453.R01.S.doc Version 5.2 Page 11 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 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service provided activities and services that were age-appropriate and valued by service users and promoted their independence. EVIDENCE: Each of the three service users were being provided with a good variety of weekly activities. These included day services, adult education, lunch clubs and a craft class. These activities were recorded at the front of each service user’s personal file. One of the service users proudly showed the Inspector a blanket she had made at a day centre and spoke of her enjoyment in going there. A home support worker who completed the postal survey thought that one of the service’s best points was that, “it gives service users access to services – socially and educationally”. There was much evidence that service users had a good social life and of past social networks being maintained. The Annual Business Plan made reference to ‘An in-house activity of service users’ choice two evenings a week’. The Manager said these activities included baking, beauty makeover and Bingo. The service also provided monthly day Fair Haven DS0000065893.V354453.R01.S.doc Version 5.2 Page 12 trips to places of service users’ choice – usually east coast seaside resorts. These were planned at monthly service users’ meetings using travel brochures and having a discussion based on past experiences. The Manager described a very good relationship with one set of immediate neighbours and no problems with any others. The service had a seven-seater people carrier and staff cars were also used to transport service users. The Manager stated that none of the service users could use public transport independently. The service had good links with the local community. All the service users reported, in the postal survey, that they could do what they wanted to do, when they wanted. One added that, “staff take us out in the car when we want”. The home support worker spoken to said that two service users had good contact with their family – in person, by telephone and by letter. One of these service users thoroughly enjoyed writing letters to her relatives, the staff member said. The third service user had friends she had met at church before moving to Fair Haven. She kept in regular contact with these friends. The health professional who completed the postal survey confirmed that, during her involvement with the Home, she had noted that service users’ privacy and dignity were respected. The home support worker spoken to gave examples of how these needs were met. Staff knock on bedroom doors before entering, for instance, and leave the bathroom while two of the service users take a bath. From discussion with the Manager it was also clear that service users’ right to dignity, and other rights, were being respected as well as their day-to-day responsibilities being recognised by the service. The Manager said that service users were involved in food shopping, preparation and clearing up after meals and there were rotas in place for some of these activities. Food stocks were at a good level in the kitchen and included fresh fruit and vegetables. The four-week rolling menu indicated that service users were being provided with a balanced and nutritious diet. Care plans made reference to service users’ food likes, dislikes and preferences. Fair Haven DS0000065893.V354453.R01.S.doc Version 5.2 Page 13 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 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service was providing service users with personal support in the way they preferred and required and was meeting their health needs. EVIDENCE: The Home had equipment in place that maximises service users’ independence. This included an electric lifting chair in the bath, a TV loop for one service user with a hearing impairment and a walking frame for one service user. One home support worker stated, in her postal survey, that “service users’ needs are always paramount to those who care for them”. Others reflected this statement in their survey forms. There was evidence, at this inspection, of staff supporting service users to maximise control over their lives. The health professional who completed the postal survey said, “My impression was of a small caring home where residents are supported to be as independent as possible and to live as part of the community”. Within the care planning documentation there was evidence of service users’ health needs being met, although there were no person centred health action plans in place. This was discussed with the Manager. Assessments of service users’ nutrition and tissue viability were being kept up to date. A medical diary Fair Haven DS0000065893.V354453.R01.S.doc Version 5.2 Page 14 recorded health appointments and on-going health issues. There was recorded evidence of appropriate involvement of health professionals, along with results and action taken. This included the involvement of a physiotherapist who stated in the postal survey, that, Staff acted upon the advice I gave, helping (the service user) to use a new walking aid and to purchase a more suitable chair”. This health professional also commented that, the carers did meet (the service user’s) health needs and followed her care plan”. Service users’ Medication Administration Record (MAR) cards were examined and found to be satisfactory. The service had a Medicines Policy in place and a record of sample staff signatures and initials. Service users’ prescribed medication was being kept securely and was administered from original containers. All staff had been provided with a distance learning course on the safe use of medicines and there were annual in-house drug assessments, the Manager explained, comprising an audit and staff refresher training. Fair Haven DS0000065893.V354453.R01.S.doc Version 5.2 Page 15 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 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures for handling complaints and abuse were in place, ensuring that service users were protected. EVIDENCE: The service’s written complaints procedure was displayed in the entrance hall and comprised a satisfactory mixture of text and pictures. There had been no formal complaints since the previous inspection. Two informal complaints were recorded in a small book that had very little detail. This was discussed with the Manager. She said that her Service Manager keeps the associated paperwork. A Compliments Book contained positive comments from service users’ relatives. The service had a written policy, on the prevention of abuse, that made reference to the Derbyshire Joint Procedures to which it was attached. Derbyshire safeguarding adults report forms were in place. The Manager reported that all staff had attended a training course in ‘Safeguarding Adults’. She said she had undertaken a two-day training course, in 2004, with Derbyshire Social Services. The home support worker spoken to showed good awareness of the service’s ‘whistle blowing’ policy. All service users confirmed, in the postal survey, that staff treat them well and that they know who to speak to if they are not happy. A check of service users’ personal money records revealed a small discrepancy – evidence of a lack of balance checks not being undertaken at every transaction as per the service’s stated policy. There was recorded evidence of the Company undertaking annual audits. Fair Haven DS0000065893.V354453.R01.S.doc Version 5.2 Page 16 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 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users were living in a generally well-maintained and hygienic environment but poor heating in the Home could lead to service users and staff being cold. EVIDENCE: The premises were attractive and homely with good quality furnishings and floor covering and it was well decorated. One service user showed the Inspector her bedroom. This was nicely personalised and included a computer, which supported her attendance at computer class. The Home was cold on the morning of the inspection and an ‘urgent action’ letter was sent to the registered provider. In response, additional heating was installed as a temporary measure and then adjustments were made to the central heating system to ensure the premises were kept warm. The garden was attractive and well maintained by staff and service users. The Manager said that service users were involved in planting items in the garden, including a raised flower bed. Fair Haven DS0000065893.V354453.R01.S.doc Version 5.2 Page 17 The Home was clean and free from odours. There were hand drying facilities and soap in the bathroom and toilet. The washing machine had a high temperature programme to ensure adequate hygiene and the home support worker spoken to provided evidence of good hygiene practice in relation to the transportation of infected materials around the Home. One of two wheely-bins was dedicated to take disposed continence materials. All staff had been provided with infection control training, the Manager stated. Fair Haven DS0000065893.V354453.R01.S.doc Version 5.2 Page 18 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): 32,33,34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service had a group of well-recruited and trained staff to ensure that service users were safe and their needs were met. EVIDENCE: Two of the service’s care staff had achieved a National Vocational Qualification (NVQ) to level 2 and one of these had NVQ level 3. The National Minimum Standard is to maintain a staff group with at least 50 qualified staff and so this standard is met. The Manager stated that the other two staff were working towards achieving NVQ level 2. The service’s staff rota was examined. These indicated that sufficient staff were being employed to ensure service users’ needs were being met. However, the rota was not always legible and correcting fluid had been applied in places. No staff had been recruited since the previous inspection when all the legal requirements regarding the recruitment of staff were found to be met. The Manager stated that service users were involved in staff recruitment in so far as she observes candidates interactions with them and they comment Fair Haven DS0000065893.V354453.R01.S.doc Version 5.2 Page 19 themselves. There was good retention of staff: no one had left the Home within the previous 12 months. Staff had been given copies of the General Social Care Council’s Code of Conduct & Practice. There was evidence of new staff having been provided, in the past, with induction training to Skills for Care Induction Standards, as recommended by Standard 35. Training records showed that all staff had been provided with all mandatory training. Many of these staff spoke positively, in their postal surveys, about the support and training provided. There was no training matrix to give an ‘at a glance’ view of training undertaken and this was discussed with the Manager. Fair Haven DS0000065893.V354453.R01.S.doc Version 5.2 Page 20 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 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service was well managed so that service users were protected and their best interests were promoted by the systems in place. EVIDENCE: The Manager had achieved her National Vocational Qualification (NVQ) in Care at level 4 and the Registered Manager Award. She had worked with people with learning disabilities for 22 years and had been in this post since 2002. The home support worker spoken to said, “There’s excellent communication between everyone” in the service. Other aspects of standard 38 were not assessed on this occasion. Monthly independent audit visits to the service on behalf of the Registered Provider, as required by Regulation 26, were taking place and were Fair Haven DS0000065893.V354453.R01.S.doc Version 5.2 Page 21 documented comprehensively. The service had a current 2007/8 Business Plan although this had no target dates to aid monitoring and review. Quality assurance questionnaires had been sent to the relatives of all three service users earlier during the week of this inspection, the Manager said. The opinions of service users were also being surveyed. However, questionnaires had not been sent to staff or external professionals involved with the Home, and this was discussed with the Manager. The minutes of the monthly service users’ meetings were read and these clearly illustrated the fact that service users are encouraged to voice their opinions. Good food hygiene practices were observed. Mild cleaning products were being stored in an unlocked kitchen cupboard and the Manager pointed out that service users make use of these products to clean floors, toilets and bathroom. There was, however, no risk assessment to address this situation. Product Information Sheets, as required by the Control Of Substances Hazardous to Health (COSHH) Regulations were kept in the staff room. Weekly fire alarm tests were recorded as well as weekly day time fire drills – with night time fire drills being held every six months. The Manager confirmed the existence of written risk assessments for the Home’s environment. The completed AQAA questionnaire indicated that equipment in the Home was being maintained and good Health and Safety practices followed. Fair Haven DS0000065893.V354453.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 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 X 2 3 3 X 4 X 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 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 Fair Haven DS0000065893.V354453.R01.S.doc Version 5.2 Page 23 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. 1. Standard YA24 Regulation 23(2)(p) Requirement An assessment of the service’s central heating system must be undertaken, and action taken accordingly, to ensure the premises are kept warm for service users and staff. Additionally, temporary sources of heating must be supplied while this matter is being pursued. These matters have been undertaken. Timescale for action 26/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA6 YA19 YA22 Good Practice Recommendations The document called ‘My Action Plan’ should be completed for each service user. The introduction of person centred health action plans should be considered. Complaints should be recorded in sufficient detail to be able to identify that appropriate action had been taken. A copy of the associated paperwork should be maintained DS0000065893.V354453.R01.S.doc Version 5.2 Page 24 Fair Haven 4. 5. 6. 7. 8. 9. YA23 YA33 YA35 YA39 YA39 YA42 within the Home. Balance checks of service users’ personal money should be undertaken on a regular basis. Staff rotas should be legible. Correcting fluid should not be used so as to ensure an audit trail can be followed. A training matrix should be developed to give an ‘at a glance’ view of staff training undertaken. The service’s Business Plan should include target dates to aid monitoring and review. Quality assurance questionnaires should be devised and sent to staff and external professionals involved with the service. A recorded risk assessment should be in place to address the storage of mild cleaning products in an unlocked kitchen cupboard. Fair Haven DS0000065893.V354453.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Fair Haven DS0000065893.V354453.R01.S.doc Version 5.2 Page 26 - 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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