Inspection on 03/05/06 for Havelock House

This inspection was carried out on 3rd May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Havelock House 01/09/09

Havelock House 18/12/08

Havelock House 17/01/08

Havelock House 26/04/07

Havelock House 04/10/05

Havelock House 19/04/05

Havelock House 21/12/04

Havelock House 06/07/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Havelock House 57 - 59 Victoria Road Polegate East Sussex BN26 6BY Lead Inspector Kathy Flynn Key Unannounced Inspection 3rd May 2006 12:30 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 Havelock House DS0000013997.V289721.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. Havelock House DS0000013997.V289721.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Havelock House Address 57 - 59 Victoria Road Polegate East Sussex BN26 6BY 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) 01323-482291 Mr Bhardwaj Dhunnoo Mrs Tarramattee Dhunnnoo Vacant Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Havelock House DS0000013997.V289721.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is twenty seven (27). The service can provide up to twenty-six (26) nursing place and one (1) social care place. Service users must be aged sixty-five (65) years of age or over on admission. 4th October 2005 Date of last inspection Brief Description of the Service: Havelock House is registered to provide nursing care for up to 26 older people and personal support for one. Situated in a residential area of Polegate, it is within walking distance of the high street and the railway station, with a library, GP and dentist surgeries easily accessible. The home is on two floors with a shaft lift and stair lifts giving residents access to all parts of the home. There are 21 single rooms 3 double rooms with no ensuite facilities, although there are two assisted bathrooms, an assisted shower and a number of assisted toilets. There is a large lounge, looking out to the rear garden that is accessible to wheelchairs and is used when weather permits, and a separate dining room. Havelock House DS0000013997.V289721.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out on the 3rd and 11th of May and took place over 11 hours. The inspection included a tour of the home, a review of pre-admission assessments, care plans, accident records, staff records and training, medication records, activities, policies and procedures and menus. There were 19 residents at the home during the inspection, and the fees range from £450 to £600 per week. All the residents and a number of visitors were spoken with and those who expressed an opinion were happy to discuss the support provided at the home. The acting manager, the nurse on duty, senior carers, the care staff and the cook discussed the care and support they provide at the home. It Pre-inspection questionnaire 10 residents/relative surveys were sent to the home prior to the inspection, and 10 relatives are comment cards were sent after the inspection. Three completed surveys and five completed comment cards were returned to the Commission, the Pre-inspection questionnaire has not been returned. The reader should aware that the Care Standards Act 2000 and the Care Homes Regulations 2001 use the term service user to describe those living in care home settings. However for the purposes of this report those living at Havelock House will be referred to as residents. What the service does well: What has improved since the last inspection? Havelock House DS0000013997.V289721.R01.S.doc Version 5.2 Page 6 The Statement of Purpose and Service Users Guide have been reviewed and updated to include details that enable prospective residents and relatives to decide if the home can meet their needs. A number of improvements have been made to the internal environment the dining room has been redecorated and the furniture replaced, the lounge has been redecorated and the kitchen units have been replaced. 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. Havelock House DS0000013997.V289721.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 Havelock House DS0000013997.V289721.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Quality in this outcome is good. This judgement has been made using available evidence including a visit to the service. The homes Statement of Purpose and Service Users Guide provide relevant information, which enables prospective residents and relatives to decide if the home can meet their needs. Pre-admission assessments are completed for all prospective residents, to ensure that the home can meet their individual needs, prior to the offer of a place at the home. EVIDENCE: The acting manager stated that she has reviewed the Statement of Purpose and Service Users Guide, they now include all the relevant information to enable prospective residents and their relatives to decide if the home can meet their needs. Havelock House DS0000013997.V289721.R01.S.doc Version 5.2 Page 9 Pre-admission assessments are completed by the acting manager prior to the offer of a place in the home, they include details of referrals to other health professionals and are used as the basis for the care plans. Havelock House DS0000013997.V289721.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome is adequate. This judgement has been made using available evidence including a visit to the service. There is no clear and consistent care planning system in place to adequately provide staff with the information they need to satisfactorily meet the assessed needs of residents. The staff are able to show an understanding of residents needs which enables them to provide support in care. EVIDENCE: The care planning system has improved and includes risk assessments, Waterlow scores and pressure relieving information, wound care charts and daily records. Despite the considerable amount of information available for each resident the care plans did not reflect the changing needs of some residents in the home. The nutritional assessments and weights had not been completed for all residents, and some residents or relatives had not signed an agreement for the use of bed barriers. Havelock House DS0000013997.V289721.R01.S.doc Version 5.2 Page 11 Residents who expressed an opinion said that the staff are ‘very good’ and offer the support they need, ‘like getting up and washing’. The acting manager showed that she has developed and introduced an audit system to assess the effectiveness of the care planning system, and this should be used to highlight any failures in the current system and identify any training needs for staff. Residents are registered with GP’s and have access to allied health professionals if required. The acting manager has identified the need for residents to have a wheelchair assessment or referral to the Speech and Language Team (SALT) and has acted upon this. The acting manager has introduced a new system for medication. Training has been provided for staff and the consultant pharmacist has been involved in developing an audit tool, which will ensure that the home uses a safe system for ordering and administering medicines. GP surgeries have been informed of the changes. Policies and procedures for the receipt, storage and administration of medicines are to be reviewed and updated to reflect the changes that the acting manager has introduced with regard to the medication. Havelock House DS0000013997.V289721.R01.S.doc Version 5.2 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The residents would benefit from a varied programme of activities. The routines of the home are flexible they enable residents to choose how they spend their time and residents can receive visitors at any time the wish. The meals provided at the home are poor, residents are not offered quality meals and there is no evidence that their nutritional needs are being met. EVIDENCE: The acting manager stated that the local church visits each month and external entertainers attend on a regular basis, but activities are not provided for residents each day. Staff were noted to be sitting talking to residents in the afternoon and staff spoken with said they try and spend some time with all the residents during the day. Staff also stated that they did not know what activities some residents would enjoy, particularly those with a dementia type illness, and they have received no training in offering these residents appropriate social support. Havelock House DS0000013997.V289721.R01.S.doc Version 5.2 Page 13 The acting manager expects one of the new members of staff to act as an activity person, she will be required to discuss with the residents and their relatives what their interests and preferences are and develop a program of activities around this information. The routines of the home are usually quite flexible, some residents choose to sit in the lounge while others prefer to spend their time in their own rooms watching television or reading. However during the inspection it was noted that a group of residents were sitting in wheelchairs in the lounge for over one hour, some of these residents usually spend most of the day in their own room and most of them are not wheelchair users. The nurse on duty explained that they are being weighed today. This practice of weighing residents at a time that is suitable for staff was identified as inappropriate. A system should be developed and introduced that enables staff to weigh residents at a time that is convenient for each resident, to ensure that it does not have a detrimental affect on their day to day living. The meals at the home have previously been found to be good, with residents offered choices and variety. However the full-time cook has recently left, her replacement now works seven days a week and said during the inspection that he has not completed a Food Hygiene Course and is not a trained to cook. Concerns about the food provided at the home were highlighted in the residents/relative survey forms received prior to the inspection and in feedback from the residents and staff during the inspection. These included the lack of choice, poor quality, badly cooked food as well as concerns about poor hygiene in the kitchen. Staff said that the mealtimes are important for residents at the home as the majority look forward to them, for some it is an important social activity where they can sit down with other residents and staff to ‘chat’ if they want to. During the inspection residents were offered a choice at lunchtime but several did not eat the meal and staff explained that most of the lunch provided on the previous day was thrown away. Staff and residents explained that they have raised their concerns about the food with the management but there have been no improvements, the cook stated that he did not know that there was a problem with the food. The acting manager stated that residents are offered a choice and they are provided with a variety of meals throughout the week, in line with the menu. The menu did list a choice for each meal, however residents and staff stated that they were not always offered what was on the menu, and it was identified that residents are not provided with the five fruit and vegetable portions a day that are recommended by the government. It was noted that some sauces in the fridge were out of date, and the cook did not know when others had been Havelock House DS0000013997.V289721.R01.S.doc Version 5.2 Page 14 opened, these may have been past their use by date. Environment Health were contacted regarding the issues identified during the inspection. Havelock House DS0000013997.V289721.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. A complaints procedure is in place. However the management does not act to improve the service when residents, relatives and staff raise concerns. Staff have a good understanding of adult protection issues which protects residents from abuse. EVIDENCE: There have been no complaints to the Commission concerning Havelock House since the last inspection. The acting manager discussed the one complaint that she has received concerning staff not washing clothes properly and causing damage. This was resolved with the person making the complaint, and staff were given the appropriate training to prevent it happening again. Policies are in place for dealing with complaints, but the feedback obtained during the inspection, regarding the meals provided at the home clearly identified that the management failed to address the concerns raised by residents, relatives and staff. Havelock House DS0000013997.V289721.R01.S.doc Version 5.2 Page 16 Staff confirmed that they have attended training in Adult Protection. They were able to demonstrate a good understanding of whistle blowing and abuse, and what action they would take if they had any concerns. Havelock House DS0000013997.V289721.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of décor in the home has improved with some areas homely and comfortable for residents. Systems for the control of infection are in place to protect residents. EVIDENCE: Some improvements have been made to the internal environment of the home, the dining room has been redecorated, tables and chairs replaced. The room is much more attractive with pictures, plants and a CD player used to provide relaxing music during meals. Kitchen units have been replaced and the lounge has been redecorated. The acting manager explained that the flooring in the kitchen, the hall, the dining room and the lounge will be replaced next. However, there was no evidence Havelock House DS0000013997.V289721.R01.S.doc Version 5.2 Page 18 that a maintenance plan has been produced to deal with ongoing maintenance at the home. The lounge is quite large and is used by a number of residents and their families when they visit. But it is also used to store wheelchairs and the hoists are placed in the corner of the room so that they can be charged. Alternative storage facilities should be provided for aids at the home so that the residents can benefit from a relaxed and comfortable space. The hot water temperature in the residents’ rooms and the shower room continues to vary from cool to hot and an effective system of regulating this has yet to be implemented. The acting manager confirmed that the central heating system is to be serviced during the summer months. The bathroom on the ground floor is used for storage and has a bath seat with a cover that is stained. It would be inappropriate for this to be used by residents, the acting manager explained that the bath is not used and did not know if any improvements were planned so that it is suitable for residents use. There is an attractive garden to the rear of the home that is accessible to wheelchair users and one resident was enjoying the warm weather with staff during the inspection. Policies and procedures are in place for the control of infection, and staff were able to demonstrate a good understanding of protecting residents using gloves and aprons appropriately. Havelock House DS0000013997.V289721.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome is adequate. This judgement has been made using available evidence including a visit to the service. The staffing levels are adequate and meet the assessed needs of residents. The procedures for the recruitment of staff are not robust and do not provide a safeguards to offer protection to residents. Induction training is not provided for staff therefore they are unable to demonstrate a clear understanding of their roles. EVIDENCE: There were 19 residents at the home during the inspection. The staff confirmed that they felt able to meet their needs with the numbers of staff on duty, although they felt that if the number of residents increased then they may be unable to do this. Some relatives comment cards raised concerns that staff take a long time to answer call bells and this delays the care they need. The expectation is that as the number of residents at the home increases the acting manager will review the staffing numbers and their skill mix, to ensure that the assessed needs of the residents can be met. The acting manager confirmed that one member of staff has recently completed the NVQ Level 3 and they would like other staff to work towards NVQ qualifications but the difficulty is finding an appropriate provider. The Havelock House DS0000013997.V289721.R01.S.doc Version 5.2 Page 20 home does not meet the 50 requirement of staff trained to NVQ Level 2 or equivalent. The home does have an appropriate recruitment policy, however it was noted that this has not been followed for the two most recent employees. There was evidence of only one reference for one employee and although POVA firsts had been completed the nurse on duty and senior carer said that they had not been informed of this and had thought that CRB checks had been completed. Therefore they had asked one carer to work on her own, if they had been given the correct information they would not have done this, because they are aware that staff who are waiting for the CRB checks should be supervised at all times. The acting manager said that some staff have started to do induction training, one carer started in December and has yet to complete it. Other members of staff spoken with during the inspection have not completed an appropriate induction programme. A key worker system has been introduced and staff spoken with during the inspection explained that they are responsible for communication with the families and friends of residents. The acting manager said that as part of the key worker system staff are expected to write any relevant information in the care plans. However some staff are reluctant to do this and further training will be required. Havelock House DS0000013997.V289721.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37 and 38 Quality in this outcome is poor. This judgement has been made using available evidence including a visit to the service. The management of the home is inadequate to meet the assessed needs of residents. The systems for residents’ consultation are poor with little evidence that residents’ views are sought and acted upon. Some practices at the home do not promote and safeguard the health, safety and welfare of residents. EVIDENCE: There has been no registered manager at Havelock House since February 2005. The acting manager is a registered nurse and has been in place since Havelock House DS0000013997.V289721.R01.S.doc Version 5.2 Page 22 December 5th 2005. An application to register with the Commission as manager has not yet been received. The acting manager demonstrated an understanding of the needs of residents, she has reviewed the Statement of Purpose and Service Users Guide and has developed an audit to be used for the care plans. However the audit did not identify the discrepancies, noted during the inspection, between the information recorded in some care plans and the care that was needed and provided. A quality assurance and monitoring system is not in place at the home. There was no evidence that feedback is sought from residents, relatives or friends regarding the services offered at the home, but there was evidence that management do not act to address any concerns raised. The acting manager confirmed that the home does not take responsibility for the finances of residents. The registered nurse and care staff stated that formal supervision is not provided at the home. The acting manager said that she was planning to introduce it and had started to assess the staffs training needs so that she could develop an appropriate system. Policies and procedures need to be reviewed and updated to ensure that they meet the NMS, the acting manager said she has started to do this. It was noted during the tour of the home that staff continue to prop the doors to resident’s rooms open. It was suggested that residents doors are only propped open when staff are providing care and support, but visitors stated that doors are kept open using bed tables and chairs if residents like them open. This has been highlighted during the previous inspections and requirements have been made for the management to obtain advice from the fire service regarding an appropriate safe system. Training required by legislation, including moving and handling and fire training is provided for all staff. Two members of staff had not completed moving and handling training and were expecting to do this the following week. Havelock House DS0000013997.V289721.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 1 X 3 1 X 1 Havelock House DS0000013997.V289721.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 OP7 Regulation 15 Requirement The care plans are to reflect the assessed needs of residents, to include all risk assessments, the use of bed barriers to enable staff to provide appropriate care. Training for staff to be provided. Nutritional assessments and weighing of residents to be carried out by staff trained to do so. That the service users social, cultural, religious, recreational interests needs are assessed and provision made to ensure these needs are met. Previous timescale of 19/04/05 and 16/01/06 not met. Care to be provided in such a way that residents are able and encouraged to make choices about all aspects of their day to day lives. Meals provided at the home are to be nutritious and wholesome and planned on the basis that residents are offered a choice. An appropriate complaints procedure is to be followed at all times to address concerns and DS0000013997.V289721.R01.S.doc Timescale for action 01/06/06 2. OP8 12 (1)(a) 01/06/06 3. OP12 16 (2)(n) 01/06/06 4. OP14 12 (2) 03/05/06 5. OP15 16 (i) 03/05/06 6. OP16 22 03/05/06 Havelock House Version 5.2 Page 25 7. OP19 13 8. OP27 18 (1)(a) 9. 10. OP28 OP29 18 (1)(a) 19 11. OP30 18 (1)(a)(c) 12. 13. OP31 OP32 9 12 & 15 14. OP33 24 & 26 15. OP36 18 (2) complaints raised about the services provided at the home. An ongoing maintenance programme to be developed and introduced to ensure the safety of residents. Previous timescale of 28/11/05 not met. Staffing numbers to be reviewed in line with the assessed needs of residents. Previous timescale of 01/11/05 not met. A minimum ratio 50 care staff trained to NVQ Level 2 or equivalent. The homes recruitment policies to be followed at all times. Previous timescale of 01/11/05 not met. An induction programme in line with TOPSS to be developed and introduced. Previous timescale of 19/04/05 and 16/01/06 not met. The home’s acting manager to register with the CSCI. A management approach to be developed to ensure the involvement of residents and relatives in developing the services provided. Previous timescale of 16/01/06 not met. An effective quality assurance and monitoring system to be implemented. That the registered provider visits the home in accordance with Regulation 26 and provides a written report that is accessible to the CSCI. Previous timescale of 06/03/06 not met. A programme of formal supervision to be developed and introduced. Previous timescale of 19/04/05 and DS0000013997.V289721.R01.S.doc 03/07/06 03/05/06 07/08/06 03/05/06 03/07/06 03/07/06 03/05/06 06/07/06 07/08/06 Havelock House Version 5.2 Page 26 16. OP37 17 Schedules 3&4 13 (4)(c) 17. OP38 16/01/06 not met. Policies and procedures to be reviewed and updated. Previous timescale of 19/04/05 and 06/03/06 not met. Advice to be sought from the Fire Service regarding the provision of safe systems for keeping residents doors open. Previous timescale of 19/04/05 and 01/11/05 not met. 07/08/06 01/06/06 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 Havelock House DS0000013997.V289721.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 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 Havelock House DS0000013997.V289721.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!