Inspection on 19/02/07 for Fair Havens Christian Home

This inspection was carried out on 19th February 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Fair Havens Christian Home 23/12/08

Fair Havens Christian Home 15/01/08

Fair Havens Christian Home 11/01/06

Fair Havens Christian Home 14/06/05

Fair Havens Christian Home 09/02/05

Fair Havens Christian Home 03/08/04

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Winton House

Newbeech House

Treloar College

Rush Court

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

CARE HOMES FOR OLDER PEOPLE Fair Havens Christian Home 468 Winchester Road Southampton Hampshire SO16 7DD Lead Inspector Anita Tengnah Unannounced Inspection 19th February 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Fair Havens Christian Home DS0000011425.V325904.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Fair Havens Christian Home DS0000011425.V325904.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fair Havens Christian Home Address 468 Winchester Road Southampton Hampshire SO16 7DD 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) 02380 790874 02380 777478 Fair Havens Christian Home Mrs Christine Newman Care Home 23 Category(ies) of Dementia - over 65 years of age (23), Old age, registration, with number not falling within any other category (23), of places Physical disability over 65 years of age (8) Fair Havens Christian Home DS0000011425.V325904.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. A maximum of 8 service users may be accommodated in the PD(E) category who are in receipt of personal care only. A maximum of 10 service users in the OP category may be accommodated who are in receipt of nursing care. 11th January 2006 Date of last inspection Brief Description of the Service: Fair Havens Christian Care Home is a small homely care home with nursing that accommodates twenty-three service users. The age range for admission to the home is 65 years and over. Fair Havens is registered to accommodate up to eight service users who are physically disabled but are in need of personal care only and up to ten service users in the old age category who are in need of nursing care. The home is registered to care for twenty-three service users over 65 years of age with dementia. The home consists of a two-storey building with a newer purpose built ground floor extension. Seventeen of the twenty rooms are single occupancy accommodation and three rooms are double occupancy. Eight of the twenty rooms have en-suite facilities. The home has a well maintained landscaped garden and patio areas for sitting in. Fair Havens Christian Care Home is situated in a residential area on the outskirts of Southampton city and has easy access to all of the local amenities. The current fee charged is £425-£660. Fair Havens Christian Home DS0000011425.V325904.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit to the service was undertaken as part of the inspection on the 19th of February 2007. The process included a tour of the service where a number of the bedrooms, communal areas, kitchen, and bathrooms were viewed. As part of case tracking 5 staff and 7 service users views were sought and care records were looked at. Information gained from the pre inspection questionnaire was also used and included in this report, as was information gathered by the commission since the last inspection to contribute in assessing judgements in this report. Positive comments were received from the service users regarding the care that they were receiving at the home. The commission did not receive any comment cards from the service. Care practices observed at the time of the visit showed that the staff and the service users had developed good relationships and care was provided in a respectful manner. What the service does well: What has improved since the last inspection? The home has introduced nutritional risk assessments for the service users on admission that reflects their dietary needs and how these would be met. Fair Havens Christian Home DS0000011425.V325904.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 Havens Christian Home DS0000011425.V325904.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fair Havens Christian Home DS0000011425.V325904.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The pre admission assessment process is poor, as the service users’ needs were not assessed prior to moving into the home. The home does not provide intermediate care. EVIDENCE: The care records of three recently admitted service users were looked at as part of case tracking. There was no documentary evidence to show that a preadmission assessment of their needs was carried out. The manager reported that she had visited one of the service users. Fair Havens Christian Home DS0000011425.V325904.R01.S.doc Version 5.2 Page 9 The manager should ensure that a needs assessment to include all aspects of personal care, mobility, diet, communication, continence and skin integrity as described in standard 3 is completed prior to admission to the home. There was no evidence that family members are involved as appropriate in order to ensure that all care needs are identified. The manager was aware that assessments from care managers should be sought as appropriate as part of the pre admission process. The manager reported that the service users are offered the choice of visiting the service prior to admission. One of the service users spoken with said that he knew about the home as his sister had been a resident previously and he had settled down well. An assessment was carried out on admission and recorded in care plans. The manager confirmed that the service does not provide intermediate care. Fair Havens Christian Home DS0000011425.V325904.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care plans and records of care given were satisfactory. Further development such as moving and handling assessments should be put in place. The health care needs and access to external agencies are well managed. The medication management was poor. The management of prescribed medication and self- medication process need reviewing in order to safeguard the service users. The service users are treated with respect and dignity and their right to privacy maintained. EVIDENCE: Fair Havens Christian Home DS0000011425.V325904.R01.S.doc Version 5.2 Page 11 The care plans of 4 service users were seen as part of this visit to look at how the home plans to meet the needs of the service users. The care plans were formulated on admission and long- term assessments were in place. Care plans included mobility and nutritional needs. The manager discussed that new care documentation was being developed and staff were working towards completing these. There appeared to be some uncertainty with regards to long- term assessments documentation and care plans that the manager was addressing. The carers were involved in recording care provided in the daily records. Some of the care plans should be further developed to include details of type of help needed with personal care to ensure that all care needs are met. Two of the records seen did not contain moving and handling assessments and the manager stated that this would be rectified. The manager should ensure that the care plans are reviewed on a monthly interval to ensure that any changes in the service users’ needs are identified and action taken as appropriate. Service users spoken with were complimentary regarding the care that they were receiving. Three service users said that they were assisted as required. Comments included “the staff are very good”. A relative was highly complimentary about the care that her relative was receiving and commented that the staff cannot be faulted. It was evident from comments received and interaction observed that the staff have formed good relationships with the service users. The manager reported that the home had developed and maintained good relationship with the local primary care trust and felt supported. All the service users are registered with the local surgeries. The GP visited the home on request. Advice was sought as required from external healthcare professionals, such as referrals to speech therapist for swallowing assessments and advice on nutrition. The home had good process of recording GP visits and also other healthcare professionals to inform practice and identified any changes in treatment plan. The home has a medication policy and procedure in place. All medications were stored securely including those that should be kept in the fridge and controlled drugs. Staff reported that the registered nurses were responsible for the administration of medication and that regular updates in medication was available. A sample of the Medication Administration Record (MAR) sheets seen indicated that some records were maintained. However there were a number of occasions that MAR sheet were blank and no indication whether the prescribed medication had been administered. There was one service user who was self medicating, this was poorly managed as the MAR sheet did not contain a record of his medication. It was also noted that a service user was selfadministering oxygen that was not prescribed and no guidance on how much oxygen and how often he was having oxygen. It was evident that the home was failing to follow its own procedure for self- medication and the Royal Pharmaceutical guidance. The manager must ensure that all prescribed Fair Havens Christian Home DS0000011425.V325904.R01.S.doc Version 5.2 Page 12 medication is recorded on the MAR sheets and consent gained by the GP for the service users who wish to self medicate and records of these are maintained to ensure the safety of the service users. The manager reported that the current system in place the staff did not see the repeat prescription as the chemist dealt with these directly from the GP. The home was also provided with printed labels that they stuck onto the MAR sheets, again this is contrary to good practice guidance. A copy of the Royal Pharmaceutical guidance has been provided to the manager following this visit. The manager reported that she would be undertaking a review of the medication management within the home. Eight service users and a relative were spoken as part of the visit. They confirmed that the home provided a good service and they had autonomy and choice regarding the activities of daily living. Comments included “the staff are excellent”. Service users said, “staff are very good and kind”. Another service user said that chose when he went to bed and get up. A relative commented that the staff were very good and that her relative “had good care”. Staff were observed to knock prior to entering the service users bedrooms and attended to the service users in a courteous and respectful manner. Fair Havens Christian Home DS0000011425.V325904.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. The service users are supported to maintain links with the community and their family and friends. The service users autonomy and choices are respected in their activity of daily living. The meals at the home are well managed offering choices to the service users and meet with their satisfaction. EVIDENCE: Fair Havens Christian Home DS0000011425.V325904.R01.S.doc Version 5.2 Page 14 The home has a planned and varied programme of activities for the service users. The five service users spoken with said that they enjoyed the activities offered and the links with the people from the church. The home has a supportive Christian ethos and two of the service users said that they had known each other for a number of years through the church and had retained this relationship now that they were both residents at the home. The home has a weekly service on Tuesdays and also monthly on Sunday evenings that the service users stated they took part in and enjoyed. A visiting physiotherapist attended the home on a weekly basis and undertook group/ one –to one exercise session with the service users. Daily newspapers were available and a mobile library visited the home every three months when the service users could select/ exchange a variety of books. The manager reported that the home had recently introduced music for health programme and other activities included external entertainers, quiz, craft and musical afternoons. The home has an open visiting policy and it was evident from the record of visitors as kept by the home that there was no restriction on visiting. Three service users confirmed that they have autonomy to receive their visitors in private but usually chose to stay in the communal lounge or the dining room. The service users spoken with said that they have autonomy and choice with their daily living activities. A service user commented that the staff attended to him “whenever I need them”. Another service user said, “nothing is too much, the staff are good”. Screens were available in the shared room as required. The home has a planned menu that is rotated on a regular basis. Comments from the service users indicated that the meals were very good and hot and cold drinks were available at all times. Comments included “very good food” and “always hot and plentiful.” Meals available included pureed diets and diabetics. Lunchtime meal was observed on the day of the visit, and meals appeared wholesome, appetising and balanced. Staff were available to offer support with meals as required. Fair Havens Christian Home DS0000011425.V325904.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The recording and investigation of complaints need reviewing to ensure that up to date records are maintained. The complaint procedure should be updated to contain current information. The staff have clear understanding of adult protection ensuring that the service users are protected. EVIDENCE: The home has a complaint procedure in place and the service users spoken with stated that they would speak to the manager if they had any concerns. The complaint procedure seen is outdated and does not contain information required such as the name, address and telephone number of the current registration body. The log indicated that there had been no complaints since the last visit. However record seen in one care plan showed that a service user had raised concerns about some missing money. There was no record in the log that this had been investigated. This was brought to the attention of the manager who must ensure that all complaints/ concerns raised are recorded, investigated and outcome of the investigation recorded. The home has clear guidance and procedures in place about what to do if there are any allegations of abuse. Staff spoken had good understanding of adult Fair Havens Christian Home DS0000011425.V325904.R01.S.doc Version 5.2 Page 16 protection issues and their responsibilities in reporting any such incidence. The home has the Hampshire Adult protection procedure and local procedure about action to be taken if abuse is suspected. The manager confirmed that the 6 staff who have completed NVQ 2 had received training in adult protection. Fair Havens Christian Home DS0000011425.V325904.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides the service users with a homely and clean accommodation that meets their needs. The infection control procedures at the home are satisfactory and ensure that the service users are protected. EVIDENCE: A tour of the premises was undertaken as part of the visit and a number of bedrooms, communal areas, bathrooms, and kitchen, laundry were viewed. Fair Havens Christian Home DS0000011425.V325904.R01.S.doc Version 5.2 Page 18 The home was clean and homely. Furnishing was of satisfactory standard and appropriate to the needs of the service users. The service users are provided with ample communal areas where a variety of activities are undertaken. The service users’ bedrooms seen were personalised and a service user said that he was able to bring in items of personal belongings on admission to the service. It was noted that some of the chairs in the communal areas were stained and should be included as part of the programme of refurbishment of the service. Staff could not confirm if a refurbishment programme was available at the time of the visit. The home has a laundry where all the service users laundry is undertaken internally. The area was in satisfactory condition and washing machines were fitted with sluicing programmes. Hand washing facilities were available and information on infection control was available to the staff. Practice observed indicated that they were aware of this and protective equipment such as gloves and aprons were available. Fair Havens Christian Home DS0000011425.V325904.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The staffing numbers should reflect the assessed needs of the service users. The home has system in place to ensure that staff have the skills to deliver care safely. The recruitment process is poor. CRB and POVA checks and references must be obtained prior to employment to ensure the safety of the service users. There is a good training programme in place to ensure that staff are supported in their work. EVIDENCE: The home has a duty roster for nurses and carers and a separate roster for ancillary workers. A sample of the staff roster indicated that there are 1 trained staff and 5 carers on the early shifts, and 1trained staff and 3carers on the afternoon shifts. The night staff included 1 trained and 1 carer and 1 sleeping carer. Staff and service users spoken with said that staffing “was all right”. However the carers had to undertake the laundry as there was no Fair Havens Christian Home DS0000011425.V325904.R01.S.doc Version 5.2 Page 20 laundry staff employed. Comments from the service users were that the staff “ did their best” and “were very good”. Two of them said that they waited for assistance at times when the staff were busy. The duty roster should be reviewed to ensure that the all staffing hours are clearly identified to include in what capacity the staff are employed. This should also include the sleeping hours of the night staff. The manager must ensure that care staffing hours are not eroded by non- care duties. The home has a number of the care staff who have achieved their NVQ level 2 and 3 in care. Information received indicated that 33 of the carers have achieved this training. The staff spoken with were enthusiastic about their jobs and felt supported by their training. The manager reported that six carers had registered with the local college in February 07 to undertake NVQ training at level 2. Three of the carers spoken said that “this was a very good home “ to work at and that they enjoyed their work. Comments received and practices observed at the time of the visit suggested that the staff have developed good relationships with the service users and each other and work well as a team and supported each other. A relative and three of the service users spoken with were highly complimentary about the staff and the care that they provided. A sample of 4 recently recruited staff records was seen as part of case tracking. The staff completed an application form as part of the recruitment process. The manager reported that she interviewed all the staff prior to employment. Some of the staff had checks undertaken and some had references including one from the last employer. However all the staff records seen showed that they had been employed prior to confirmation of their Criminal Record Bureau (CRB) checks had been received and there was no records of POVA first checks obtained prior to employment. There was no evidence that another carer had registered to work in this country and also had no references. These matters were brought to the attention of the manager and a requirement will be issued. The home has an ongoing training programme and information about future training was displayed. Staff said that training was good and that they had completed mandatory health and safety training. Recent training included 10 staff members who had completed training in dementia care. Other training /updates were infection control, three monthly fire training, food hygiene and manual handling. Fair Havens Christian Home DS0000011425.V325904.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The financial interests of the service users are safeguarded through good accounting. The home is run in the best interests of the service users, however the process of seeking the service users’ views is not satisfactory. There is a satisfactory procedure in place to ensure the health and safety of the service users is promoted. A risk assessment for the environment was available. EVIDENCE: Fair Havens Christian Home DS0000011425.V325904.R01.S.doc Version 5.2 Page 22 The home has a registered manager who is also a registered nurse. The staff, service users and visitor spoken with all said that the manager is available when they needed her and that she operated an open door policy. The manager had developed good relationships with her staff and the staff were supportive of her. The home does not have an internal audit system in place to seek the views of the service users/ relatives and other healthcare professionals. This had been highlighted at the last two visits and no action has been taken to date. The operational manager does regular visits in line with Regulation 26 and records of these were maintained. There was no evidence of a business plan in place and the manager reported that a plan for maintenance and refurbishment of the service was being developed at head office. A sample of three of the service users’ personal allowance as managed by the home was seen. This indicated that receipts of all transactions were maintained and records of invoices raised were also available. Random checks of the service users’ personal account were found to be accurate. All transactions undertaken with the service users were recorded accurately. The administrator said that the operational manager also undertook a random audit of the service users’ personal moneys as maintained at the home. Information received indicated that there are regular reviews of policies and procedures to ensure that they meet current legislation/ guidelines. Record indicated that the fire officer last visited in December 06 where a number of requirements were raised. The manager reported that the head office was preparing a schedule and the work remains outstanding at present. There is an ongoing programme for the servicing of fire equipment, hoists, wheelchairs, lift and emergency lighting. Records seen showed that they were all completed in the last 6 months. Substances that are hazardous to health (COSHH) were kept locked away. Fair Havens Christian Home DS0000011425.V325904.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Fair Havens Christian Home DS0000011425.V325904.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14(1) (a) Requirement The registered manager must ensure that there is a thorough pre-admission assessment process where all service users needs are assessed prior to admission to the home. The registered manager must ensure that a record is maintained of all prescribed medication and the date that these are administered to the service users. The registered manager must ensure that there is a robust procedure in place for service users who are self medicating, including a risk assessment and consent from the GP. The registered person must ensure that a record of all complaints made is maintained and includes details of investigations and any action taken. The registered manager must ensure that there is a robust recruitment procedure in place. DS0000011425.V325904.R01.S.doc Timescale for action 15/04/07 2 OP9 Reg. 17(1) (a) Schedule 3 (k) 13(4) (c ) 15/04/07 3 OP9 15/04/07 4 OP16 17(2) 15/04/07 5 OP29 19(1) 15/04/07 Fair Havens Christian Home Version 5.2 Page 25 6 OP33 Reg. 24 (1)(2) All checks including CRB, POVA first, references are obtained prior to employment in order to safeguard the welfare of the service users. The manager must establish a system to improve and review the services delivered in the home, by seeking the opinions and views of the service users and/or their representatives. This was a requirement from the last inspection and timescale of 31/03/06 has not been complied with. 15/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Fair Havens Christian Home DS0000011425.V325904.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Fair Havens Christian Home DS0000011425.V325904.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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