CARE HOME ADULTS 18-65
Haven Lodge Care Home 2 Alexandra Street Sherwood Rise Nottingham NG5 1AY Lead Inspector
Stephen Benson Key Unannounced Inspection 18th December 2006 09:30 Haven Lodge Care Home DS0000002232.V322850.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 Lodge Care Home DS0000002232.V322850.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 Lodge Care Home DS0000002232.V322850.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Haven Lodge Care Home Address 2 Alexandra Street Sherwood Rise Nottingham NG5 1AY 0115 962 1675 0115 910 9879 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) Mr Wesley John Stala Care Home 11 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (11), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (3) Haven Lodge Care Home DS0000002232.V322850.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The 3 named service users be accommodated within the establishment. A Variation must be submitted to CSCI for any additional out of category service users. 31st January 2006 Date of last inspection Brief Description of the Service: Haven Lodge is a three storey converted, semi-detached building, offering accommodation for 11 service users with mental health problems, 2 of whom are now over 65 years of age. (The registration has been amended to reflect that these individuals can be accommodated for as long as their needs continue to be met).The care home accommodation is on two floors, and there is no lift access to the second-floor, this may pose difficulties for persons with physical mobility problems. There are 11 single bedrooms now that the double room has been converted to provide two single bedrooms. A variety of communal facilities are also provided. There is a garden area to the rear of the building and paved area to the front of the building. The home is situated in a mixed residential and office area, a short distance from the city centre. There are good transport links in the area. The senior care stated on 18/12/2006 that the fees for the service are £290 per week. Haven Lodge Care Home DS0000002232.V322850.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 visit to the home since 1st April 2006 by The Commission for Social Care Inspection. Prior to the visit an analysis of the home was undertaken from information gathered over the last year. The site visit lasted for 4 ½ hours and the main method of inspection used was called case tracking which involved selecting 3 residents and tracking the care they receive through the checking of their records and discussing this with them. Other residents were spoken with and additional records were seen. A discussion was had with the manager, senior care, staff on duty and care practices were observed. No visitors were present during the inspection. The premises were not inspected in detail but various areas of the home were visited as part of the inspection. Survey forms sent to the home by The Commission for Social Care Inspection had been completed by the majority of residents were seen. What the service does well:
There have not been any recent admissions to the home, but there is a system in place to assess any prospective new resident. Files seen had assessments in them and the senior care said Community Care Assessments are received before anyone can be assessed to come to the home. The evidence shows that new residents are assessed before they come to live at the home. Staff said they provide residents choices where possible and residents spoke of choosing how they spend their time. The evidence shows that residents make decisions about their lives with assistance as needed. Risk assessments were completed and assessed physical and psychological factors. Residents spoke of using equipment in the kitchen and going out unescorted. The evidence shows that residents’ are supported to take risks as part of an independent lifestyle. Some residents attend a local day centre where they can meet and mix with others and participate in appropriate activities. Residents spoke of spending their time how they wished and using community resources. The evidence shows that residents are able to take part in age, peer and culturally appropriate activities. Residents use local facilities including pubs, healthcare services, clubs and shops. The evidence shows that residents are part of the local community. Haven Lodge Care Home DS0000002232.V322850.R01.S.doc Version 5.2 Page 6 Some residents have contact with their families and residents can have friendships with people outside of the home that do not exploit them. The evidence shows that residents have appropriate personal and family relationships. Staff spoke of there not being set routines. Residents are able to make choices they are able to, for example the time they get up and go to bed. The evidence shows that residents’ rights are respected in their daily lives. Residents are able to choose what they have to eat and are not restricted by a set menu. Records showed that there are a variety of meals provided and residents are able to exercise their preferences. The evidence shows that residents are offered a varied diet and enjoy their meals and mealtimes. Staff said residents see to their own personal needs as much as possible. Residents said they are reminded by staff to keep clean. The evidence shows that residents receive personal support in the way they prefer and require. A record is made of all healthcare appointments attended and these showed that residents access a variety of services including eye tests and psychiatric appointments. A resident spoke of having some new glasses for reading. The evidence shows that residents physical and emotional health needs are met. Residents are assessed to see if they are able to self medicate. Staff have been trained in the safe storage and handling of medicines and residents confirmed they are given their medication by staff. The evidence shows that residents are protected by the home’s policies and procedures for dealing with medicines. The manager has worked at the home for a number of years and is currently working towards The Registered Managers Award. Senior staff share in the management of the home. Staff felt the home was suitably managed. The evidence shows that residents benefit from a well run home. The required health and safety checks are carried out. The evidence shows that the health, safety and welfare of residents are fully promoted and protected. What has improved since the last inspection?
A table lamp has been provided to increase the lighting so residents can play board games in the lounge. Staff have been provided with training on the safe handling, storage and administration of medicines. Haven Lodge Care Home DS0000002232.V322850.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Haven Lodge Care Home DS0000002232.V322850.R01.S.doc Version 5.2 Page 8 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 Lodge Care Home DS0000002232.V322850.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. New residents are assessed before they come to live at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have not been any recent long-term admissions to the home. Care files seen included assessments of residents’ needs carried out by the home. There have been some residents who have come for a short period of respite and the senior care said that Community Care Assessments were received before they came for their period of stay. Care staff said they are able to read about any new admissions. Assessments included details of any specialist assistance a resident requires. The manager said that anyone is welcome to apply for a place providing they fall within the registration category for the home. Haven Lodge Care Home DS0000002232.V322850.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. Residents assessed needs and personal goals are not fully reflected in their individual plan. Residents’ make decisions about their lives with assistance as needed and are supported to take risks as part of an independent lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were care plans in place for each resident, however these did not contain detail as to how residents’ needs should be met. Residents had signed the plans seen in November 2005, but those residents spoken with could not recall seeing their care plans. Staff said they read through plans to find out about residents, but don’t refer to them for meeting residents’ needs as they know these, as it is only a small home.
Haven Lodge Care Home DS0000002232.V322850.R01.S.doc Version 5.2 Page 11 The senior care said she is responsible for preparing and updating care plans and said that staff tend to know details of how to meet residents’ needs and that these are not always recorded in the care plan. The senior care said she would redo the care plans so that they describe how residents’ needs are to be met. Care plans did not show any involvement by residents in making decisions, however examples were seen where this was done, including some residents choosing to have a flu vaccination and others not. The senior care said residents are able to ‘do their own thing’ and choose how they spend their day, including whether they go out or stay at home. Staff said they always give residents choices and ask them if they want their room cleaned. Residents spoken with said, “We can help ourselves to what we want” and “We can come and go as we please”. There were risk assessments seen in residents care plans, which included physical and psychological factors. There were some risks identified that did not have details as to how these could be safely managed and it was pointed out that any risks that are identified should be included within residents’ care plans, which the senior care said she would include when redoing the care plans. The senior care said that all residents are able to leave the home unescorted and can make their own drinks and some snacks. Support is provided when needed, for example when using the bread maker. A resident said, “I tell staff when I am going out as they might wonder where I am”. Haven Lodge Care Home DS0000002232.V322850.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. Residents are able to take part in age, peer and culturally appropriate activities and are part of the local community. Residents have appropriate personal and family relationships and their rights are respected in their daily lives. Residents are offered a varied diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were details in one care plans seen of a resident attending a local day centre and having supportive relationships there. The senior care said that some residents go to local day centres some of the time and enjoy looking round the shops. The senior care said that no residents go to college at present and have not been interested when this has been suggested, but one did do a cooking course a while ago.
Haven Lodge Care Home DS0000002232.V322850.R01.S.doc Version 5.2 Page 13 Staff said that some residents go to a local day centre. A resident said, “I’m not interested in going to college, I like to sit outside and read in the nice weather, otherwise I will watch television or listen to the radio. The manager took two residents out to a local snooker club for lunch, which a resident said he did every week. The senior care said some residents have got to know local people and they use local shops and pubs. A resident said, “I walk around the local area to get some exercise”. There were no details seen in care plans of involvement with families, but staff said that some residents do have visits from their families. The senior care said some residents have contact with their families who are welcome to visit. The senior care said friendships are encouraged if positive, but staff have to be aware of their vulnerability and said that one visitor had been stopped from coming as she had been taking residents’ cigarettes. There are not records in the care plans of residents preferred routines, however the senior care said that the routines in the home are flexible. Staff said that residents decide for themselves when they want to do things. A resident said, “There is no set routine for getting up or going to bed. I can watch TV in my room”. The home does not work to a fixed menu, but a menu record is kept of all food provided. This showed that residents make differing choices and a varied diet is provided. Residents were seen having sandwiches for lunch, which they appeared to enjoy. A senior member of staff does the shopping at a local supermarket and said she tries to get different things for residents to try and they are able to suggest or make requests for things. The senior care said mealtimes are structure so residents know where they are, but these can be varied. Staff said residents are able to choose what they want to eat from what is available. Residents said, “We have three meals a day and the food is excellent” and “We get plenty to eat and we can have breakfast as late as we want”.
Haven Lodge Care Home DS0000002232.V322850.R01.S.doc Version 5.2 Page 14 The manager said that any special diet for personal choice, religious or health reasons would be accommodated. Haven Lodge Care Home DS0000002232.V322850.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. Residents receive personal support in the way they require and with respect and their physical and emotional health needs are met. Residents are protected by the home’s policies and procedures for dealing with medicines. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One resident was seen at lunchtime without any socks on and when asked about this said that he was short of socks. Staff felt that this was not the case and said he had bought some new socks recently, however staff were not aware he was not wearing any socks. The senior care said that residents are encouraged to see to their own personal care as much as possible. Staff said that one resident needs assistance with personal care and the others just need to be reminded.
Haven Lodge Care Home DS0000002232.V322850.R01.S.doc Version 5.2 Page 16 Residents said, “Staff will help us with our hygiene”. There were details of contacts residents have with healthcare services in their care plans. These included doctor, district and community psychiatric nurses, psychiatrist, optician and hospital appointments. The senior care said they are investigating using a healthcare service that visits the home and provides a complete well being healthcare service. Staff said that the manager or senior on duty makes any appointments and they pass any health concerns on to them. A resident said, “If you need to see a doctor staff book an appointment as soon as possible. I have had my eyes tested and have some glasses for reading, they are nice glasses”. One case file showed that a resident was self-medicating and staff had monitored this. When it was noted that the resident was not taking his medication regularly staff took over responsibility for giving his medication. The senior care said that some residents have self-medicated in the past but none are assessed as being able to at present. Staff said that they have been trained in the safe handling and storage of medication and that they watch residents take their medication and sign to confirm this on the Medicine Administration Records. Residents said that staff give them their tablets with their meals. Haven Lodge Care Home DS0000002232.V322850.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. Residents feel their views are listened to and acted upon but there are not systems in place to protect residents from financial abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a complaints procedure displayed on one of the notice boards and a complaints log was in the office. There were no entries in this and the manager and senior care said this would only be used for serious and formal complaints, however they felt that a further log for recording any grumbles or positive comments would be useful and plan to implement one of these. Staff said that they would write down any complaint made and give it to the manager, but had not had to do so. Residents said, “Any complaints would be mentioned to staff, but never had to yet.” and “I assume any complaint would be sorted out”. There have not been any referrals made to the Adult Protection Unit and there was a copy of the Adult Protection Procedures available as well as the home’s own policies on adult protection and whistleblowing. There was a requirement set at the last inspection to establish a reliable and auditable system of recording the management of resident’s money by any staff member. There were some records seen, however these were not in
Haven Lodge Care Home DS0000002232.V322850.R01.S.doc Version 5.2 Page 18 place for all residents and the manager said he did not always keep a record of money given to residents. The manager said he was aware that this needed to be done but the informal way the home is run makes this difficult. This requirement is repeated and must be complied with or The Commission for Social Care Inspection will consider taking enforcement action. A staff member said she had not had training on Adult Protection and did not know about the Adult Protection Procedures. The senior care said that staff have had training on Adult Protection as part of their National Vocational Training and was surprised at this comment from staff and would follow this up. A resident said, “Nobody is treated badly here, there are some rules like no violence allowed”. The senior care said that any form of abuse or discrimination would not be accepted and would be dealt with by following the Adult Protection Procedures. Haven Lodge Care Home DS0000002232.V322850.R01.S.doc Version 5.2 Page 19 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. Residents live in a homely environment, but this is not being fully maintained. The home is not suitable for wheelchair users. Infection risks are not dealt with promptly. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager showed a planned maintenance and decoration programme and areas of the home seen were well maintained with the exception of a resident’s bed, which rocked when pushed and needs to be made stable. The home is on differing levels and there is not a lift so is not suitable for wheelchair users. A resident said, “The building is just how I like it”.
Haven Lodge Care Home DS0000002232.V322850.R01.S.doc Version 5.2 Page 20 The care staff are responsible for the cleaning and were seen carrying out these duties. Generally the home seemed clean, however there was stains seen in a resident’s room, which he said was where he had been sick recently. Also there were stains from where his sink had been blocked and overflowed. Staff said this had not been cleaned up as they were waiting to be shown how to use the new carpet cleaner. Care staff were seen using protective clothing which was available in the laundry. Haven Lodge Care Home DS0000002232.V322850.R01.S.doc Version 5.2 Page 21 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. Residents are supported by competent staff who are working towards a qualification. Residents are supported and protected by the home’s recruitment policy and practices. Staff have not received all the required training. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The rota showed there is a minimum of two staff on duty during the day and evening with two sleeping in staff at night. On most days the manager or one of the other senior staff is also on duty. The home employs male and female staff and they are of varying ages and from differing ethnic backgrounds. Staff said they felt there are enough staff on duty. A resident said, “There is always at least two staff on duty, which seems to be enough”.
Haven Lodge Care Home DS0000002232.V322850.R01.S.doc Version 5.2 Page 22 Staff files seen showed that the correct recruitment practices are followed, although the previous employment history was not as clear as it could be. There was not a written training plan and staff training records were not up to date so it was not possible to establish what training each member of staff has had. The senior care said that seven staff are currently enrolled on National Vocational Qualification training in care level 2. Staff said they have done the safe handling of medicines course and are currently working towards National Vocational Qualification level 2. Haven Lodge Care Home DS0000002232.V322850.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. Residents benefit from a well run home but the views of residents do not influence the self monitoring, review and development by the home. The health, safety and welfare of residents are fully promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager, who is also the provider, has been in post for a number of years and is currently enrolled on The Registered Managers Award. There are two senior staff who assist with the running of the home and have areas of responsibility delegated to them. Haven Lodge Care Home DS0000002232.V322850.R01.S.doc Version 5.2 Page 24 The majority of residents had completed the surveys sent to the home by The Commission for Social Care Inspection. There are not any quality assurance systems in place for the manager to review the quality of care provided in the home and these are required. The senior care said that all the required health and safety checks are carried out at the required frequency and there are service contracts in place for servicing all the equipment. Dates of tests were recorded in the pre inspection questionnaire showing they are regularly carried out. A sample of these were looked at and found to be correct. Haven Lodge Care Home DS0000002232.V322850.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 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 X 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 39 X X 3
43 3 X 2 X X 3 x Haven Lodge Care Home DS0000002232.V322850.R01.S.doc Version 5.2 Page 26 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 YA6 Regulation 15 Requirement The registered person must ensure that care plans include details of all residents needs and how these are to be met. The registered person must ensure that all beds are well maintained. The registered person must establish a reliable and auditable system of recording the management of resident’s money by any staff member.
(Repeated requirement – previous timescale of 28/02/06 not complied with) Timescale for action 01/03/07 2 3 YA24 YA23 16 13 01/01/07 14/01/07 4 YA30 23 5 YA35 18 6 YA39 24 The registered person must 23/12/06 ensure that all areas of the home are kept clean and do not pose a risk of infection. The registered person must 01/04/07 ensure that all staff have received the required training and a record is kept of all training staff have. The registered person must 01/02/07 establish and maintain a system for reviewing and improving the quality of care at the home.
(Repeated requirement – previous timescale of 31/03/06 not complied with) Haven Lodge Care Home DS0000002232.V322850.R01.S.doc Version 5.2 Page 27 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 YA34 Good Practice Recommendations The registered manager should ensure that a clear record is made of new staff’s previous working history. Haven Lodge Care Home DS0000002232.V322850.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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