Inspection on 27/06/05 for Haven Lodge

This inspection was carried out on 27th June 2005.

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

Haven Lodge 03/10/07

Haven Lodge 10/10/06

Haven Lodge 21/02/06

Haven Lodge 24/11/04

Haven Lodge 09/08/04

Similar services:

Kings Lane (32)

Pemdale

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

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

CARE HOME ADULTS 18-65 Haven Lodge 14 Wellesley Road Clacton on Sea Essex CO15 3PP Lead Inspector Pauline Dean Unannounced 27 June 2005 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 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 Stationary 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 Lodge v218258 i56_io5_s17844_havenlodge_v218258_ui270605_stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Haven Lodge Address 14 Wellesley Road Clacton on Sea Essex CO15 3PP 01255 421089 01255 223641 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Paul Wilkinson Mrs Catherine Covey Care Home 9 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (9), Learning disability (9), Mental of places disorder, excluding learning disability or dementia - over 65 years of age (3), Learning disability over 65 years of age (3) Haven Lodge v218258 i56_io5_s17844_havenlodge_v218258_ui270605_stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may care for nine people with learning disabilities who may also have a mental disorder. 2. Three persons, aged 65 years and over, who require care by reason of a learning disability who may also have a mental disorder, whose names were made known to the National Care Standards Comission in March 2003. 3. The total number of service useres accomodated must not exceed nine persons. Date of last inspection 24th November 2004 Brief Description of the Service: Haven Lodge is an established residential care home registered under the Care Standards Act 2000 for nine service users with learning disabilities and/or mental health disorders. There is single bedroom accommodation for all nine service users located on the ground floor, first floor and second floor. One service user has their own en-suite facilities. There is a bathroom and shower room on the first floor and a further bathroom on the second floor. There is a separate toilet on the first floor and toilets in the first floor shower room and second floor bathroom. Communal facilities consist of a front lounge and a rear dining room/day room. The home is a semi-detached property within walking distance of Clacton town centre where there are shops, churches, markets, cinema, theatre, sea front amenities and the esplanade. GP surgeries are also close by. There are front and rear gardens with off the road parking on the driveway. The rear garden is paved with shrub and flowerbeds. At the rear of the property there are outbuildings which house the home’s laundry/ utility room, storage and smoker’s room. The home’s office is located on the first floor. Haven Lodge v218258 i56_io5_s17844_havenlodge_v218258_ui270605_stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place over one day in June 2005. This was the first inspection of the inspection year 2005 – 2006. Mrs Catherine Covey, the registered manager was present throughout the inspection and the registered provider, Mr Paul Wilkinson visited the home to attend a staff meeting. Mr John Kelly, consultant for the care home visited the home during the inspection. During this inspection three care staff were interviewed and both the cleaner and handyman were working in the home. All of the service users were met during the inspection and five of the nine service users were spoken with during the day. Service users from the other care home owned by Mr Wilkinson visited Haven Lodge with their staff for a BBQ at lunchtime, followed by a joint staff meeting. No other visitors or relatives visited during the inspection. A tour of the premises was conducted at this inspection and both care and staff records were sampled. In addition some policies and procedures were sampled and inspected. Twenty-nine of the forty-three standards were inspected, of these twenty-two were met with seven standards almost met. What the service does well: Haven Lodge is an established care home for adults with a learning disability and mental health disorders. Several of the service users have lived at the care home for many years. For some this was prior to the current registered provider, Mr Paul Wilkinson and the introduction of the National Minimum Standards. Haven Lodge offers a homely environment with service users able to come and go as they please. The independence of service users is encouraged with easy access to the town and facilities of Clacton on Sea. Haven Lodge looks to itself as being part of the local community, with service users encouraged to involve themselves in local activities. Some service users are able to access both leisure and educational pursuits as they wish. In addition, the home has a caravan sited at St Oysth, which is shared with the other care home, with service users able to have holidays of varying lengths at the caravan and enjoy the facilities and activities of the holiday park. Haven Lodge v218258 i56_io5_s17844_havenlodge_v218258_ui270605_stage4.doc Version 1.30 Page 6 What has improved since the last inspection? 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 Lodge v218258 i56_io5_s17844_havenlodge_v218258_ui270605_stage4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Haven Lodge v218258 i56_io5_s17844_havenlodge_v218258_ui270605_stage4.doc Version 1.30 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 standard(s) 1 and 2. Clear detailed information by the way of the Statement of Purpose and the Service Users’ Guide are provided to enable placing authorities, prospective service users and their families to make a choice as to whether or not they might wish to live at Haven Lodge. A detailed and thorough pre-admission assessment is in place to ensure that the home can meet the assessed needs and aspirations of prospective service users. EVIDENCE: Amendments and changes have been made to both the Statement of Purpose and the Service Users’ Guide, and these now meet requirements. There have been no new admissions since the last inspection, but evidence was found on the most recent admission of a detailed pre-admission assessment. Haven Lodge v218258 i56_io5_s17844_havenlodge_v218258_ui270605_stage4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 and 9. Service users’ assessed needs and personal goals are detailed in their individual care plans. These plans, however, had not been reviewed and revised to ensure that personal care needs are met. Care planning records detail service users’ right to make decisions about what they wish to do and staff enable service users to take responsible risks with both risk assessments and risk management strategies in place. EVIDENCE: Care plans and risk assessments for three service users were sampled and inspected. A variety of primary goals have been set covering all aspects of personal and social support, and healthcare needs. Whilst detailed primary goals have been set, to cover these requirements, care plan reviews had not taken place. Dates had been set for February/March 2005 but reviews had not occurred. The registered manager, Mrs Cathy Covey, acknowledged this shortfall and spoke of involving service users in the development and review of their care planning primary goals. This was further substantiated by the inspector in a conversation with a service user who spoke of ongoing review and changes to their care plan. In addition monthly reviews and records demonstrated a need to update and review care planning primary goals. Haven Lodge v218258 i56_io5_s17844_havenlodge_v218258_ui270605_stage4.doc Version 1.30 Page 10 Risk assessments were found to be in place. The three care plans sampled evidenced this and discussions with two service users detailed examples of how they were able to take responsible risks. Haven Lodge v218258 i56_io5_s17844_havenlodge_v218258_ui270605_stage4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15, 16 and 17. Service users are supported and enabled to have opportunities for personal development through the provision and promotion of appropriate leisure, educational and work activities in the community. Family and personal contact are open and relaxed, with family links promoted and encouraged. Haven Lodge offered a varied planned menu, giving consideration to dietary requirements. EVIDENCE: Two service users spoke positively regarding their work placements. They said that they enjoyed their work and outlined some of the tasks they undertake. Mrs Covey, the registered manager, said that she wished that there were opportunities for other service users but, in spite of looking for placements, the home had not been able to access further appropriate work experience opportunities. Haven Lodge v218258 i56_io5_s17844_havenlodge_v218258_ui270605_stage4.doc Version 1.30 Page 12 One service user spoke of their past attendance at a art/craft class and they said that they were hoping to access an art class in the autumn and a Christmas Decoration class in November 2005. Records showed that service users are supported and assisted in participating in community life. One service user attends church regularly with all of the service users accessing shops, cafes and leisure activities as they wish. Service users are assisted or escorted if required and are enabled to use public transport. Both this home and the other care home owned by Mr Paul Wilkinson have the use of a mini bus. This is parked on the Haven Lodge forecourt. This transport is used by the homes to access the local Gateway club (a social club) and for holidays at the caravan in St Oysth. Four of the service users spoken with said that they had enjoyed their holiday last year at the caravan. They said that they had made use of the facilities and activities at the holiday park such as the evening entertainment. They all said that they were looking forward to a trip to the caravan again this year. Two service users said that they visit or meet with their relatives regularly. One service user said that they enjoy weekly shopping trips to Colchester with their relative, and another service user said that they had visited their family to celebrate their birthday. Records sampled also detailed contact with relatives via the telephone and letters. During this inspection care staff were seen to be respectful towards service users. Examples of care staff talking and interacting with service users at the lunchtime BBQ were observed. Haven Lodge operates a four-week rotation menu with some flexibility such as on the day of inspection when a BBQ was taking place. The main meal of the day is at lunchtime although service users who are out for the day may have their main meal in the evening. The dietary requirements of one service user (low fat diet) are accommodated through the menu planning. Haven Lodge v218258 i56_io5_s17844_havenlodge_v218258_ui270605_stage4.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20 and 21. Service users receive personal support as they require and in a manner that they prefer. Record keeping and planning for meeting health care needs was found to have some shortfalls and did not detail fully if service users’ physical and emotional health care needs are met. The administration of medication for service users was found to be detailed and well recorded to help ensure that their healthcare needs are met. Whilst consideration has been given within policies and procedures to the management and care of the dying further consideration is needed regarding individual needs such as ageing. EVIDENCE: Three service users said that they are offered personal support as they require and prefer. Care plan records evidenced this. They were able to outline their healthcare requirements and visits to consultants and GPs. Whilst it was acknowledged by the registered manager that these appointments had taken place record keeping did not fully detail these visits. Haven Lodge v218258 i56_io5_s17844_havenlodge_v218258_ui270605_stage4.doc Version 1.30 Page 14 Medication storage, administration and medicines entering and leaving the home were sampled and inspected for three service users. The records were found to be in good order with adequate secure storage. Mrs Covey, the registered manager, said that all staff undertake some medication training within their NVQ training workbooks. A new procedure entitled ‘Procedure for the Care of the Dying’ has been adopted by the home. This made mention of the physical care of the dying, pain control, emotional care, supporting relatives and friends, religious needs and notifications and registration of deaths. Whilst it was acknowledged that this procedure encompasses good care practice, Mrs Covey, the registered manager was reminded of the need to consider the individual care needs of the resident group, such as ageing and mobility, in their continued care at Haven Lodge. Haven Lodge v218258 i56_io5_s17844_havenlodge_v218258_ui270605_stage4.doc Version 1.30 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23. Appropriate practices were in place to help ensure that service users’ views are listened to and acted upon, and their protection is promoted. Staff training, the awareness of management and staff, policies and procedures and staff recruitment practices safeguard this. EVIDENCE: The home’s complaint procedure was inspected and found to requirements. There have been no complaints since the last inspection. meet At the time of inspection the Adult Protection Procedure was said to need revision and review. Mr Kelly, the home’s consultant, agreed to undertake this work and a copy of the policy entitled ‘Suspicion of Abuse’ has been sent to the Commission for Social Care Inspection (CSCI). This policy makes reference to the Department of Health guidance ‘No Secrets’ and local authority guidance and abuse definitions. Training is said to be through National Vocation Qualification (NVQ) training input. Copies of local authority guidance ‘Protecting Vulnerable Adults’ were said to be given to all care staff and management hold further local authority guidance for making Protection of Vulnerable Adults (POVA) referrals. Haven Lodge v218258 i56_io5_s17844_havenlodge_v218258_ui270605_stage4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 and 30. Haven Lodge provides a safe, homely and pleasant environment, which was clean and comfortable. EVIDENCE: A tour of the premises was undertaken at this inspection and the accommodation was found to be clean, tidy, bright and free from offensive odours. Decoration and maintenance are ongoing with a planned maintenance programme in place. Internal decoration had been completed in one bedroom and new radiator covers were seen. Additional double electrical sockets have been fitted and three new sink units have been installed. Carpeting had been replaced in one room and further carpeting is required in a further two bedrooms. The home is in keeping with the local community, blending in with other residential accommodation in the area. Recent renovation to the pathway, garden and the vehicle stand-in has greatly improved the front aspect of the property. A new front door and replacement windows add to this. Haven Lodge v218258 i56_io5_s17844_havenlodge_v218258_ui270605_stage4.doc Version 1.30 Page 17 Bedroom accommodation seen reflected the personality of the occupant with evidence of personal property, such as CD players, televisions and radios. One service user spoke of being involved in the choice of colour and furnishings in the decoration and décor of their room. Laundry facilities are located in outbuildings at the rear of the garden. One service user spoke of their involvement in changing their bed and managing their personal laundry needs. They were complimentary regarding the efficiency and management of the laundry service at Haven Lodge. Haven Lodge v218258 i56_io5_s17844_havenlodge_v218258_ui270605_stage4.doc Version 1.30 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34, 35 and 36. Staffing levels, skills and competency are appropriate to the needs of service users. Staff recruitment practices and procedures had shortfalls and do not ensure that services users are supported and protected. An induction and a basic staff training programme ensure that training and skills requirements are met. EVIDENCE: From interviewing two care staff members and observing a third carer, staff were found to have an understanding of the needs and requirements of service users. Four care staff were said to be on National Vocational Qualifications (NVQ) level 2 with approximately 50 of the course to complete. From discussion with management and reviewing staff rotas staffing levels, as recommended by the Department of Health Guidance – Residential Forum Guidance, were found to be met. Mrs Covey acknowledged that there is a need for an ongoing review of staffing levels to ensure that service users needs are met in full at all times. Five service users spoken with confirmed that there are sufficient staff for them to access leisure and educational activities and attend work placements. Some service users require escorts; others do not need an escort. Haven Lodge v218258 i56_io5_s17844_havenlodge_v218258_ui270605_stage4.doc Version 1.30 Page 19 The files of three care staff were sampled and inspected. Overall references and checks were in good order, with the exception of the most recent staff member. Whilst a detailed CV had been presented employment history was not complete. From speaking to the staff member concerned it was also unclear whether they had completed a new Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) check. Mrs Covey was urged to seek clarification and progress immediately as necessary. Evidence of a TOPSS (Skills for Care) induction-training course was seen. Mrs Covey, the registered manager, spoke of an ongoing review of the home’s training programme with three staff booked on basic food hygiene training and fire safety training. Mrs Covey said that she had recently obtained a Moving and Handling Assessor’s qualification and further training on this aspect of care is to be progressed within the home. Regular recorded supervision sessions are held in the home. Records seen evidenced this and two staff interviewed confirmed that these sessions have taken place. Support and guidance and training needs and issues are discussed at these meetings. Haven Lodge v218258 i56_io5_s17844_havenlodge_v218258_ui270605_stage4.doc Version 1.30 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 41 and 42. Staff and service users are well supported by the home’s manager, who is hands-on and part of the care team in the home. An effective quality assurance and quality monitoring system is still required for analyses of completed questionnaires needs to be undertaken. Shortfalls identified in staff recruitment checks failed to ensure that service users’ rights and interests are safeguarded. Safety certifications were found to be in place to help ensure that the health, welfare and safety of service users were protected and promoted. EVIDENCE: Mrs Covey, the registered manager, said that she is nearing completion of the National Vocational Qualification (NVQ) level 4 in care and management. She is hoping to complete this summer. Haven Lodge v218258 i56_io5_s17844_havenlodge_v218258_ui270605_stage4.doc Version 1.30 Page 21 Questionnaires were said to have been completed by service users. It was recognised that there is a need to disseminate these questionnaires to develop an annual development plan based on a systematic cycle of planning-actionreview. The results of which will need to be published and made available to service users, their representatives and other interested parties. Staff recruitment records had shortfalls as detailed earlier in this report (see National Minimum Standard 34). The need to ensure that all record keeping was up-to-date and accurate was highlighted with Mrs Covey, the registered manager. As at the last inspection the need to comply with the requirement to Regulation 26 visits by the registered provider was highlighted as a This was raised with both the registered manager and the registered Copies of formats for the presentation of these visits have been sent Lodge. complete shortfall. provider. to Haven Safety certification was seen for both electrical installation and Portable Appliance Testing (PAT). These were current and met requirements. Hot water record keeping and monitoring is ongoing and this was found to meet requirements. Haven Lodge v218258 i56_io5_s17844_havenlodge_v218258_ui270605_stage4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x 3 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Haven Lodge Score 3 2 3 2 Standard No 37 38 39 40 41 42 43 Score 2 x 2 x 2 3 x v218258 i56_io5_s17844_havenlodge_v218258_ui270605_stage4.doc Version 1.30 Page 23 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 6 Regulation 14, 15 Requirement The registered manager must develop and agree with each service user an individual care plan which is reviewed with the service user at least every six months. The registered manager must ensure that healthcare needs of service users are addressed and record keeping clearly details these needs. The registered manager must ensure that individual service users needs are considered with regard to ageing, illness and death. Individual care plans need to be agreed and reviewed regularly. The registered manager must operate a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. (This is a repeat requirement. Previous timescale of 09/01/05 not met.) The registered person must ensure that effective quality assurance and quality monitoring systems are in place to measure success in achieving the aims, Timescale for action 15/08/05 2. 19 16 15/08/05 3. 21 14, 15 15/08/05 4. 34 17, 18 15/08/05 5. 39 24 15/08/05 Haven Lodge v218258 i56_io5_s17844_havenlodge_v218258_ui270605_stage4.doc Version 1.30 Page 24 6. 41 17,18,24, 25, 7. 41 26 objectives and the statement of purpose of the home. (This is a repeat requirement. Previous timescale of 09/01/05 not met.) The registered manager must review record keeping to ensure that records for the effective and efficient running of the business are maintained, up to date and accurate. This is with regard to staff recruitment records. (This is a repeat requirement. Previous timescale of 09/01/05 not met.) The registered provider must ensure that visits are made in accordance with Care Home Regulations 2001 - Regulation 26. (This is a repeat requirement. Previous timescale of 09/01/05 not met.) 15/08/05 15/08/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 37 Good Practice Recommendations The registered manager should ensure that they complete the NVQ level 4 in care and management in the immediate future. Summber 2005 is the anticipated timescale for completion. . Haven Lodge v218258 i56_io5_s17844_havenlodge_v218258_ui270605_stage4.doc Version 1.30 Page 25 Commission for Social Care Inspection 1st Floor, Fairfax House, Causton Road Colchester Essex CO1 1RJ 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 Lodge v218258 i56_io5_s17844_havenlodge_v218258_ui270605_stage4.doc Version 1.30 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!