Inspection on 03/08/06 for Haven House (Haslemere)

This inspection was carried out on 3rd August 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Haven House (Haslemere) 03/07/07

Haven House (Haslemere) 29/09/05

Haven House (Haslemere) 26/04/05

Haven House (Haslemere) 02/09/04

Haven House (Haslemere) 04/05/04

Haven House (Haslemere) 04/02/04

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33 St John`s Church Road

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

CARE HOME ADULTS 18-65 Haven House (Haslemere) Haven House 44 Kings Road Haslemere Surrey GU27 2QG Lead Inspector Pauline Long Key Unannounced Inspection 3rd August 2006 12:00a Haven House (Haslemere) DS0000013666.V304791.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 Haven House (Haslemere) DS0000013666.V304791.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. Haven House (Haslemere) DS0000013666.V304791.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Haven House (Haslemere) Address Haven House 44 Kings Road Haslemere Surrey GU27 2QG 01428 661440 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) Whitmore Vale Housing Association Limited Miss Phillippa Kate Alves Care Home 9 Category(ies) of Learning disability (9), Mental disorder, registration, with number excluding learning disability or dementia (1), of places Physical disability (5), Sensory impairment (5) Haven House (Haslemere) DS0000013666.V304791.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The age/age range of the persons to be accommodated will be 21 - 55 years, one (1) resident 55-65 years. All 9 (nine) residents will have a learning disability (LD). Up to 5 (five) of the residents may have a sensory impairment (SI) and/or a physical disability (PD). 1 (one) of the residents may have an additional mental disorder (MD). Date of last inspection 29th September 2005 Brief Description of the Service: Haven House is registered for a maximum of nine residents within the age range of 21-65 years. The residents have learning disabilities or an acquired brain injury. The home is managed by ‘Whitmore Vale’ Housing Association Limited and is one of a number of registered services within the county of Surrey. The home is a detached purpose built property situated close to the town centre. The home provides a homely and comfortable environment where residents are encouraged towards independence and social inclusion. The fees at the home range from £834.10 per week to £1296.24 per week. Haven House (Haslemere) DS0000013666.V304791.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first site visit of the CSCI key inspection year and was unannounced. The inspection was carried out by one inspector and it started at 12.00 midday and finished at 16.40. Discussions were held with the residents, manager, care staff and senior managers. Documents sampled, included service users files, care plans, staff records, and service files. The pre-inspection questionnaire was submitted following the site visit and has been used for the purposes of this report. Three comment cards were received from residents and three comment cards were received from relatives. A full tour of the home took place. Verbal feedback from the resident’s at home on the day was limited, in view of their communication difficulties. However direct observations evidenced contented and happy residents. CSCI would like to thank the residents, manager, care staff and senior managers for their hospitality and co-operation during the inspection. What the service does well: What has improved since the last inspection? Improvements have been made in care planning and risk assessment. New dining room furniture has been bought. Plans have been made to provide a patio area in the garden, to enable residents to spend time outside. Haven House (Haslemere) DS0000013666.V304791.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. Haven House (Haslemere) DS0000013666.V304791.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 Haven House (Haslemere) DS0000013666.V304791.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The statement of purpose and service user guide would provide prospective residents/ residents with sufficient information about the home. However the service user guide requires updating. Care needs assessments would be completed prior to a resident being admitted to the home. Each resident is provided with a contract of the care service provided at the home. However further work is required in respect of resident’s tenancy contracts. EVIDENCE: The statement of purpose and service user guide have been developed in pictorial, symbol and written format providing the residents with sufficient information about the home and. However the service user guide requires review and updating to reflect the current management arrangements at the home. The manager evidenced that an updated copy was on the homes computer, she had not had the time to print it off. It should be noted that current management arrangements have been in place for some considerable time. The manager commented that all of the residents have lived at the home since it was opened or shortly after. There was one vacant room. Care needs assessments were not sampled on this occasion as the manager stated they were archived and would be difficult to retrieve. Discussions were had in respect of the homes procedure around admission. The manager explained Haven House (Haslemere) DS0000013666.V304791.R01.S.doc Version 5.2 Page 9 that a social services care management needs assessment would be sought prior to the home agreeing to carry out their own assessment. Once in receipt of the care management assessments, staff from the home would visit the prospective resident to carry out their initial needs assessment. Prospective residents would then be invited to the home to meet the other service users and staff, these visits could range from a tea time or lunch time visit to an overnight/ weekend visit. On admission residents needs assessments would be ongoing through a two week assessment period, followed by a 3 months trial period. All of the residents had a contract of the care services provided at the home, and all had been signed by residents or their representative. However a requirement made at the previous inspection in respect of resident’s tenancy’s contracts had not been met. The manager evidenced that she had sent a letter to the social care management teams in this respect dated April 06, to date no response had been received at the home. It should be noted that the timescale set for this requirement to be met was 10/11/05. Requirements have been made in respect of these standards. Please refer to pages 24 and 25 of this report. Haven House (Haslemere) DS0000013666.V304791.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are in place for the residents, providing the staff with information and guidance as to the resident’s needs and choices. Residents were encouraged and supported to take responsible risks and to help in decision making at the home. EVIDENCE: The manager commented that improvements had been made in the residents care plan documentation. Care plans were sampled, and were found to be satisfactory, and included plans around all daily living activities. The care plans gave clear instructions and guidelines to the reader about a residents care needs, demonstrating that the care staff would be aware of these needs. Risk assessments were clearly documented and guidelines in place to minimise the risks. On the day the manager was in the process of reviewing the care plans and risk assessments, and there was evidence that some reviews had taken place. The manager was observed supporting the residents in respect of decision making and choices for example, choices for lunch and an outside activity. Haven House (Haslemere) DS0000013666.V304791.R01.S.doc Version 5.2 Page 11 One relative commented that “I continue to be impressed with the care provided and all residents are treated as individuals”. Another commented that “her relative was more able and encouraged to make decisions” since moving into Haven House. Haven House (Haslemere) DS0000013666.V304791.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. 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 residents are encouraged and enabled to maintain fulfilling lifestyles in and outside the home and promotes contact with family, friends and the local community. The meals offered in the home looked appetizing and appealing. Improvements must be made in some kitchen practices to ensure the residents health and well-being. EVIDENCE: On the day, all but one of the residents was out at their various day services. The one resident remaining in the home had attended day services in the past, but no longer wished to do so as evidenced in the care plan. The inspector observed the resident enjoying a television programme whilst eating his lunch. Later in the day the manager asked if the resident if he wished to go out to the shops, he responded by smiling and getting him self ready to go out. Two of the remaining resident group had been out to the local garden centre and returned mid afternoon. Discussions were had with them and they commented that they had enjoyed their trip and lunch at the garden centre, one Haven House (Haslemere) DS0000013666.V304791.R01.S.doc Version 5.2 Page 13 commented that she was glad to be home for a rest. The remaining residents returned to the home at 4.30pm. They were observed to happily discuss their day at the day service activities and were keen to tell the manager which activities they took part in. The manager stated, that residents are encouraged to choose their meals from pictorial and written menus. On the day of inspection one resident was observed eating a meal of meat pie with potatoes and vegetable with gravy. He was not eating very much, and was asked if he would prefer a ham and pickle sandwich, which he proceeded to eat with gusto. There was evidence in the care plans to indicate specialist diets were required for two of the residents. Clear guidelines were in place to assist staff in this area. Kitchen practices and procedures were sampled. The fridge, freezer and cupboards were well stocked. There were ample supplies of fresh fruit and vegetables. There were concerns around some food hygiene practices in respect of foodstuffs stored in the fridge, which had not been covered or dated on opening. The extractor fan was dirty, the pictorial menus were sticky and required cleaning. Requirements were made in these areas. Please refer to pages 24 and 25 of this report. Haven House (Haslemere) DS0000013666.V304791.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. 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 staff have a good understanding of the residents physical, emotional and health support needs, this was evident from the positive interactions and relationships observed. Residents are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: As discussed earlier in this report care plans included clear guidelines on any support each resident required with personal, emotional and health care needs. Daily records included visits to the doctor, various health related appointments and reviews of care. A relative commented that “staff are kind and considerate, they provide first class care, and could not be better”. I always feel that my daughter is protected, safe and happy. The manager was observed supporting a resident with personal care. Whilst on the whole this support was sensitive, there was a concern around the somewhat childish approach she used. This was discussed with her and she provided a satisfactory explanation as to the reason for her approach. Other staff were observed supporting a resident to bed for a rest. This support was Haven House (Haslemere) DS0000013666.V304791.R01.S.doc Version 5.2 Page 15 offered in a dignified manner, the bedroom door was not left open whilst this happened. Staff were heard to explain what they were doing. Entries into daily notes evidenced various visits in respect of a residents health needs, GP visits, dental care, hospital appointments. The home has clear medication policies and procedures. None of the residents at the home is responsible for their own medication. The home has notified the CSCI of 3 medication errors and the manager stated that staff responsible had been suspended from medication administration until further training was undertaken. All of staff under take external medication training as well as in house training. Care staff commented that only those staff who have been trained and assessed as competent are permitted to administer medication. Staff commented that the local diabetic nurse had provided training in respect of blood sugar monitoring. However this had been some time ago and staff may benefit from further training in this respect. Medication storage was sampled and found to be good. The manager carries out daily/weekly medication audits. The controlled drugs book was checked along with the corresponding medication and was found to be correct. There were documented protocols in place for PRN (as required medications). Medication administration was not observed on the day. A recommendation has been made in respect of these standards. Please refer to pages 24 and 25 of this report. Haven House (Haslemere) DS0000013666.V304791.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. 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. The home has satisfactory policies and procedures in place for dealing with concerns, complaints and the protection of the residents. EVIDENCE: The CSCI have received no complaints about this home since the last inspection. The manager stated that no complaints had been received at the home since the last inspection and the complaints records evidenced this. One relative commented that she was not aware of the homes complaints procedures, however she has not had to make a complaint and if she had a problem she would be happy to speak directly with the manager. One referral has been made under the Surrey Multi Agency Safeguarding Adults procedures. Meetings have been held in this respect and the issues have been satisfactorily resolved. All staff have undertaken training in safeguarding adults and discussions were had with the staff on duty in this respect. It was positive to note they demonstrated a good understanding of the current policies and procedures. One relative commented that, “I always feel that my daughter is protected, safe and happy”. A recommendation has been made in respect of the complaints procedure. Please refer to page 24 and 25 of this report. Haven House (Haslemere) DS0000013666.V304791.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. 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. The standard of the environment within this home is good and meets the needs of the residents. Improvements are required in respect of the storage of hazardous substances to ensure that the residents are protected from harm. EVIDENCE: Haven house is purpose built and was opened in 2000. Overall the building has been maintained in good order. The inside of the property provides a safe, homely and comfortable environment for the residents. The fabric and decoration of the communal areas was good. The manager commented that decoration was carried out on a rolling basis and that the dining room and the sitting room had recently been redecorated. It was noted that the lock was broken on one of the hall cupboard doors. The cupboard contained the homes hot water tank and various pieces of equipment and also another cupboard in which a bottle of hazardous liquid was stored, this cupboard did not have a lock either. The manager commented that she had informed the management company responsible for maintaining the building in respect of the broken lock. One bathroom was found to have a Haven House (Haslemere) DS0000013666.V304791.R01.S.doc Version 5.2 Page 18 bottle of hazardous liquid, which if picked up by a resident could be dangerous and cause injury. Overall the standard of cleanliness was good and residents commented that the home was cleaned every day. However some of the pillows were soiled and require replacement. As discussed earlier in this report, improvements in the cleaning regime in the kitchen are required. Requirements and a recommendation have been made in respect of these standards. Please refer to pages 24 and 25 of this report. Haven House (Haslemere) DS0000013666.V304791.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home employs a stable efficient and appropriately trained staff team and recruitment practices are good. However improvements are required in respect of staffing arrangements and formal one to one supervision meetings. EVIDENCE: The home benefits from a stable staff team, some of whom have worked at the home since it opened, indicating a consistent care service. The manager commented that staff recruitment was ongoing and that the organisation was activity recruiting care staff and she produced a copy of the most recent advertisement. She stated that the home has to use agency staff, however in order to maintain continuity of care she endeavours to use the same agency staff at all times. One relative commented that she had occasion to telephone the home and the agency member of staff who answered the phone was completely disinterested and offish and that perhaps more training was needed. The manager commented that the deputy manager was off on long term sick leave and that she was covering many of her shifts. On the day of the site visit there were 2 care staff, and the manager on duty on the morning shift. The afternoon shift was due to have 4 care staff, however one of the staff did not report for work, the manager stated that she would stay on to cover the shift. Haven House (Haslemere) DS0000013666.V304791.R01.S.doc Version 5.2 Page 20 The home has clear policies and procedures for staff recruitment. Staff files were sampled and demonstrated thorough recruitment and selection practice. One to one discussions were had with all of the staff on duty. They demonstrated that they had an awareness of their individual roles and responsibilities. Staff training is given a high priority in this home, and training records demonstrate many statutory and current good practice training had been undertaken since the last inspection. Staff are undertaking (NVQ) National Vocation Qualifications. There is a formal one to one staff supervision programme in the home. Records were sampled and evidenced that formal one to one meetings were not being held as required. There was evidence of a recent staff meeting on 09/05/06. Requirements and a recommendation have been made in respect of these standards. Please refer to pages 24 and 25 of this report. Haven House (Haslemere) DS0000013666.V304791.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements are required in respect of the management of this home to ensure that the residents welfare is protected and safeguarded and that the home is run in the residents best interests. Resident’s views are listened to and acted upon. Some aspects of health and safety in respect of the storage of hazardous substances needs to be improved to ensure that residents health and safety is promoted. EVIDENCE: The inspector contacted the operations manager for the organisation, following the site visit to the home. Feedback from staff on duty regarding concerns around the conduct and management of the service was relayed to the senior manager. Information was also provided to the responsible individual, who confirmed that appropriate action plans were in place to address the improvements in relation to the service. The quality rating for this outcome Haven House (Haslemere) DS0000013666.V304791.R01.S.doc Version 5.2 Page 22 group has therefore been assessed as adequate in view of the proactive approach by the organisation to resolve the issues and ensure the safety of the residents. The home holds resident’s meetings in which the care staff support the residents to express their views the last one was held on 13/07/06. Service user questionnaires are sent to families and other health and social care professionals. The last questionnaires were sent out in August 2005. Some of the returned questionnaires were sampled and provided a positive view of the home for example “ I continue to be impressed with the care provided, all residents are treated as individuals and are encouraged to make their own decisions”. “The staff are kind and considerate, first class care”. The manager carries out monthly house audits, and weekly medication audits, health and safety checks are routinely carried out at the home. All equipment in use on the day of inspection was properly maintained. Records evidenced that water temperatures, fire drills and fire bells were regularly checked. Kitchen records in respect of fridge, freezer and food temperatures were well kept. As discussed earlier in this report there were some concerns around the storage and control of hazardous substances. Requirements have been made in respect of these standards. Please refer to pages 23 and 24 of this report. Haven House (Haslemere) DS0000013666.V304791.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 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 2 2 3 3 X 4 X 5 2 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 2 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 1 X 3 X X 2 X Haven House (Haslemere) DS0000013666.V304791.R01.S.doc Version 5.2 Page 24 Yes 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 YA5 Regulation 5, (1) (b) Requirement The registered person(s) must ensure that residents or their representative sign and date resident’s contracts/terms and conditions of residence. Previous timescale of 10/11/05 not met. Timescale for action 03/09/06 2. YA1 5 3. YA42 4. YA42 5. YA42 YA24 6. YA26 The registered person(s) must ensure that the service user guide is amended to reflect the current management arrangements at the home. 12(1)(a) The registered person(s) must 13(4)(c ) ensure that all food is stored according to food hygiene regulations. All foodstuffs in the fridge must be dated on opening. 12(1)(a) The registered person(s) must 13(4)(c ) ensure that all areas of the home are kept clean. The extractor fan in the kitchen must be cleaned. 13(4)(a)(b) The registered person(s) must (c ) ensure that all of the homes door locks are in working order. The lock on the hall cupboard door must be fixed. 16(2)(c(e) The registered person(s) must DS0000013666.V304791.R01.S.doc 03/09/06 04/08/06 11/08/06 11/08/06 11/08/06 Page 25 Haven House (Haslemere) Version 5.2 7. YA33 18(1)(a) 8. YA36 18(2)(a) 9. YA42 12(1)(a) 13(4)(a(c ) ensure that all soiled pillows are replaced. The registered person(s) must review the staffing levels in the home, to ensure that staffing levels are adequate. The registered person(s) must ensure that all staff receive the required number of formal one to one staff supervision meetings with a manager. The registered person(s) must ensure that all hazardous substances are stored in complainence with COSHH regulations. 11/09/06 03/09/06 04/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard YA21 YA32 YA32 YA22 Good Practice Recommendations That residents or their authorised representative sign the funeral wishes arrangement forms. The registered person(s) should consider a refresher training course for all staff in the use of blood sugar monitoring equipment. The registered person(s) should consider providing training for the agency staff in respect of telephone communication skills. The registered person(s) should consider writing to all of the relatives in order to remind them of the homes complaints procedures. Haven House (Haslemere) DS0000013666.V304791.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Haven House (Haslemere) DS0000013666.V304791.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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