Inspection on 19/05/06 for Havengore House

This inspection was carried out on 19th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Havengore House 06/06/07

Havengore House 08/11/05

Havengore House 07/06/05

Havengore House 07/02/05

Havengore House 26/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Havengore House 27 Fairfield Road Eastwood Leigh On Sea Essex SS9 5RZ Lead Inspector Trevor Davey & Sarah Axam Key Unannounced Inspection 19th May 2006 09:35 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Havengore House DS0000051663.V295838.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Havengore House DS0000051663.V295838.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Havengore House Address 27 Fairfield Road Eastwood Leigh On Sea Essex SS9 5RZ 01702 529243 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) Mrs Anne Sik Yee Shum Mr Cheuk Wah Shum Manager post vacant Care Home 20 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (20) of places Havengore House DS0000051663.V295838.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Number of service users to whom personal care is to be provided shall not exceed 20 (twenty). Accommodation and personal care may be provided to no more than 20 older people over the age of 65 years (OP). Accommodation and personal care may be provided to no more than 4 service users over 65 years with Dementia (DE(E)). Total number of persons over 65 years to be accommodated must not exceed 20. 8th November 2005 Date of last inspection Brief Description of the Service: Havengore House is registered to provide personal care and accommodation for twenty older people over 65 years of age including four places for residents who have been diagnosed with dementia. The home is located at the end of a short private road of a quiet residential street in Eastwood. The premises are situated within a short walking distance of numerous bus routes, which have direct links to Rayleigh and Southend. The building is a converted and extended farmhouse in its own gardens and as such, provides spacious rooms many of which have ensuite facilities. A shaft lift has been provided. Residents in the home are encouraged to be involved in social activities both within the home and in the local community. The monthly fees, as stated in the Pre- inspection questionnaire which was submitted on 8th. May 2006, range from £360 to £440 per week. Additional charges are made for hairdressing, chiropody and taxi services. The Registered Person has copies of recent CSCI inspection reports available in the home for prospective service users and/or their relatives. Often enquirers have previously down loaded copies from the Internet web sight before visiting the home. Havengore House DS0000051663.V295838.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the fourth inspection which has taken place in the last two years. The Key inspection site visit took place over a period of 7.75 hours. As there were two inspectors, this equated to 15.50 hours on site. The visit mainly focused on the progress the home had made since the last inspection and covered all Key standards. A tour of the home took place. Staff, relatives, visiting professionals and residents were spoken with. In addition, case tracking took place using some of the personal care records and other official records within the home were also assessed. Letters were also sent out to local doctors, funding authorities and social workers requesting feedback of the service provided by the home. At the time of writing this report, responses from these agencies had not been received. Information was also taken from the pre-inspection questionnaire submitted by the Registered Provider. The home also had available questionnaires which had been completed by residents and relatives and these were taken into account when assessing the outcomes of the inspection. The fax number of the home is the same as the telephone number which is included in the service information. This, together with any other added details affecting the service information, will be included in the next inspection report. What the service does well: The home is able to demonstrate its effectiveness in consulting other health care professionals to provide advice and additional input when necessary. This ensures that newly identified care needs can be appropriately met. Positive comments were made on the day of the site visit by residents, relatives and health care professionals regarding the high standard of care provided in the home. The management have also been pro-active in obtaining feedback from users of the service by using questionnaires on a six monthly basis. Ongoing improvements have been made to the provision of social activities/outings which are varied and take into account residents choice. A good selection and variety of choice of meals is available. Havengore House DS0000051663.V295838.R01.S.doc Version 5.2 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. Havengore House DS0000051663.V295838.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Havengore House DS0000051663.V295838.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Pre-admission assessment details for care/health needs had been recorded giving staff suitable information to determine whether needs could be met by the home. EVIDENCE: From the sample check made, pre-admission details were documented which included health and physical condition as well as mobility, mental state and sensory needs. This process included a visit to the prospective service user in hospital prior to admission to the home. The pre-admission assessment procedure whilst acceptable, should also include more detail regarding social interests, hobbies and background information. The home does not provide intermediate care. Havengore House DS0000051663.V295838.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Assessed and identified care/health needs were being met appropriately with the added support of other healthcare professionals as required. Personal care records were in place although some of the content and detail need to be more specific to ensure continuity of practice. Not all funding authorities have carried out annual reviews as required. EVIDENCE: Case tracking took place in respect of two residents and other personal care records were also looked at. Basic instructions were available for key workers and daily log sheets completed by staff were up-to-date. Various areas had been identified for care input together with support such as communication, breathing, pressure area and skin care. Medical care provided by healthcare professionals had been regularly recorded and updated as and when district nurses and doctors had visited. In-house reviews take place on a monthly basis and these dates are recorded on a summary sheet but cross-referencing of these dates had not always been shown or updated on the individual elements of care plans. The acting manager stated, however, that she is due to attend a course on care planning in July. Other advice was given by the inspectors to assist in providing additional specific care plan information. Not Havengore House DS0000051663.V295838.R01.S.doc Version 5.2 Page 10 all funding authorities had carried out annual reviews as required and in one case, this had not occurred since July 2002 when the resident was admitted to the home. This issue will be taken up by the CSCI with the local authorities concerned. Turning and fluid charts had been regularly documented but some of the detail and information was not always clear to follow. The home was able to demonstrate a prompt and robust response in relation to changing needs and responding positively where falls had occurred. The Commission for Social Care Inspection had been regularly notified of incidents in the home as required under Regulation 37 of the Care Homes Regulations. Local doctors had been requested to provide medical assessments and medication had been reviewed to take account of changing circumstances. The Community Liaison Nurse had also carried out a fracture risk assessment and had given advice to the staff to ensure that care needs of residents could be appropriately met. Other alarm devices had also been purchased by the home to assist staff in minimising the risk of injury. During the inspection, conversations took place with visiting district nurses including the Practice Development Nurse. They were carrying out visits on a regular basis and the comment was made that There was a good feel about the home. Positive comments were also made regarding the acting manager who arranged for staff to be updated with moving & handling training. The staff were pro- active and the standard of care was good. They also confirmed that staff in the home have the use of disposable gloves and aprons in accordance with universal infection control procedures. Pressure areas were being contained and not developing and a good working relationship existed with the staff team. Observation during the inspection showed residents to be well cared for, clean and properly looked after particularly when requiring 24-hour bed care. Both residents and relatives spoken to, stated that the quality of care was good and that relatives were kept informed of any changes. Staff were approachable and there was always opportunity for any issues of concern to be discussed. A nomad medication system is in place for each resident. Medication is stored in a lockable cabinet and the administration records were being maintained in accordance with agreed procedures. Record sheets had been correctly recorded and signed for. Training records indicated that all staff have regular medication training. The home had carried out their own survey of the service provided and 75 of the questionnaires had been completed by residents and other questionnaires had been completed by relatives. This exercise is carried out every six months by the management and the comments on the care provided were very positive. Staff were said to be caring and helpful as well as friendly, professional and welcoming. The outcomes of the inspection showed that the health and personal care provided to residents in the home is appropriate and in accordance with their identified needs and delivered in a way which respects their privacy and dignity. Havengore House DS0000051663.V295838.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 &15 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The home provides an activities programme to meet individual’s needs. Meals take account of residents choice. Relatives and friends are encouraged to have regular contact with the home. EVIDENCE: Six residents spoken with described a number of activities that they had been involved with during the week. They also stated that staff regularly asked what they wanted to do and these requests are put into place. Within the home was an activities rota that evidence this and showed the various arrangements for each day of the week. During the time of the inspection some of the residents spoken to were playing bingo and were positive as to how well they are looked after in the home. They also mentioned that they had recently been taken out into the local community which included shopping in Southend, visits to tea rooms and to Hadley Castle. Social activities within the home include musical exercises, singing and dancing as well as cheese and sherry evenings. Church services take place on a four weekly basis. All residents have visitors to the home who are able to come whenever they choose. During the inspection, two residents’ families visited and the rapport Havengore House DS0000051663.V295838.R01.S.doc Version 5.2 Page 12 between them and staff was relaxed and positive, suggesting this is a regular occurrence and families feel comfortable within the home. Relatives spoken to confirm that residents are able to choose their own daily routines, staff are approachable and that there are regular meetings for residents. Bedrooms were also said to be regularly cleaned. Individual bedrooms evidence that residents are encouraged to bring in belongings and to personalise their rooms. Some residents have lockable cash boxes in which to keep cash and valuables if required. Residents spoke positively of the high standard of food, and drinks which are provided. Drinks and snacks are available at any time of the day or night. The menus available and the record of meals provided, evidenced this and that choice was taken into account. The cook had a good knowledge of the preferences of residents together with their dietary requirements and the need for individuals to enjoy the food provided. One of the comments from the home’s survey forms stated that improved television facilities would be welcome. This had since been addressed and two new televisions have been provided. The outcomes of the inspection showed that the residents find the daily life and social activities of the home matches their expectations and preferences as well as satisfying their social, and holistic needs in accordance with personal choice. Havengore House DS0000051663.V295838.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area was good. This judgment has been made using available evidence including a visit to this service. There is an established complaints procedure in place. Staff had an adequate understanding of the reporting procedure for the prevention of harm of vulnerable adults, ensuring that the safety of residents in the home is of paramount importance. EVIDENCE: The home’s complaints procedure is included in the service user guide and since the last inspection, the home had received one complaint about the admission of a resident to hospital and notifying the relatives. This was dealt with appropriately at the time by the home and the procedures for contacting relatives in such instances, has been updated. Staff spoken with had an adequate understanding and knowledge of P.O.V.A. reporting procedures. Records were also available of where staff had attended P.O.V.A. training. Havengore House DS0000051663.V295838.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21 &26 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Areas of the home were clean and hygienic. Improvements have been made to the flooring and the kitchen refurbished. Some improvements need to be carried out in the garden area to minimise potential hazards to residents. EVIDENCE: New flooring and carpeting has been provided in the lounge and dining areas. The kitchen has been refitted with new cupboards which includes the provision and freezer. There were no unpleasant odours in the home and bedrooms were found to be clean and personalised to reflect individual residents’choice. Although currently, the bathing and washing facilities are appropriate for existing residents, serious consideration must be given to the first-floor bathroom area which requires remodelling in order to provide a facility which is suitable for frail and/or wheelchair dependent people. This facility must also be able to accommodate a hoist and/or mechanical bath lift. This was highlighted in the previous inspection report. It was suggested to the acting Havengore House DS0000051663.V295838.R01.S.doc Version 5.2 Page 15 manager that the hand rails within the home be checked regularly and that more sturdy fittings be considered to minimise the risk of residents falling and to give greater support. The acting manager was also asked to arrange for the removal of an inside bolt from the door of bedroom no. 11 in case staff needed to gain access in an emergency. It was also noted that the door leading to the utility room/laundry was not lockable which could be a danger to residents if they accessed this area and into the garden. Some of the paving stones in the garden area are hazardous and need levelling off as residents could be at risk of falling. Universal infection control procedures were in place throughout the home but it was noted that the lid of the storage facility containing soiled waste and disposable plastic aprons, was missing and some of the plastic aprons had blown into the garden area. These storage facilities must be made secure to prevent the possible spread of infection and to maintain hygiene standards. The exterior side gate should also be made secure to ensure the safety of residents (particularly those with dementia), who may wander into the road area without the knowledge of staff. This matter must be discussed with the fire officer to ensure that quick and easy access can still be made in the event of an emergency as it is understood this is a fire escape route. In the meantime, risk assessments must be updated to ensure a safe home environment and to take account of the security of residents who may be at risk. Following this site visit, the acting manager has advised the inspector that action has already been taken to positively address these potential hazards in order to minimise the risk to the health and safety of residents. Havengore House DS0000051663.V295838.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29 & 30 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The number of staff on duty, their experience and skill was able to meet the needs of residents. Recruitment records were in place but all details need to be made available for inspection. EVIDENCE: Residents spoken with commented that they felt there were sufficient staff on duty at any one time to cater for their needs. At the time of inspection, the home was fully staffed and the skills mix of the staff group was being used positively in meeting the various needs of residents. There are two awake staff on duty at night and there are two cooks and two domestics which cover the week during the day as well as care staff. The home does not use agency workers and regular staff cover any sickness or annual leave voids. Staff rotas evidenced that there is adequate cover throughout the day and night. Training records were in place which showed the dates completed and planned. Individual staff files evidenced certificates in place of training courses that had been undertaken. Alongside mandatory and specific training of residents needs, 50 of the staff team are N.V.Q. qualified and the manager is currently studying her NVQ 4 Registered Managers Award. Staff spoken to were positive regarding the management support received and that staff meetings take place regularly. They also spoke about the training courses they had attended. Overall, staff files evidenced that all Criminal Records Bureau and identification Havengore House DS0000051663.V295838.R01.S.doc Version 5.2 Page 17 checks were in place although in one case, a current CRB was not recorded. None of the staff files had recent photographs as part of the proof of identity as required by Regulation. Havengore House DS0000051663.V295838.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Management systems are good and the home is run in the best interests of residents. The management respond robustly & rectify matters of health & safety when identified. EVIDENCE: The acting manager has had a senior position in the home for some time and has further developed her experience by attending relevant courses. She is currently studying for N.V.Q.4 Registered Managers Award and has submitted an application to the Commission for Social Care Inspection for registration. There is evidence to show that the Registered Provider and acting manager work together with staff team to develop the service and improve the standard of care in the interests of residents. Good liaison and communication takes place with relatives and other healthcare professionals. The home is Havengore House DS0000051663.V295838.R01.S.doc Version 5.2 Page 19 developing a quality assurance system and fifteen questionnaires had been completed by residents and a further six by relatives during May 2006. This process takes place every six months and positive feedback had been received regarding the caring, friendly and helpful attitude of the staff team as well as constructive ideas regarding improvements to the outside garden area. Up – to- date servicing/maintenance certificates were in place relating to the health and safety of the premises and equipment. A sample check was made of residents personal allowances which were being safeguarded by the home and financial transactions had been properly documented, signed for and with the appropriate receipts on file. Staff have had training on a universal infection control procedures and these were being followed but storage facilities for soiled waste/materials needs to be more secure. This has since been rectified. Access to the laundry/utility area needs to be secure to prevent residents from wandering into this area where they could be at a potential risk. Some of the paving slabs in the garden area were raised and uneven which is hazardous to residents. The side gate was open and this needs to be made secure to prevent residents, particularly with dementia, wandering into the road and endangering themselves. As this is a fire escape route, the Registered Provider must consult with the fire officer to ensure that a satisfactory solution can be agreed to provide a free evacuation route whilst at the same time, minimising the risk of residents wandering into the outside road without the knowledge of staff. Risk assessments for a safe environment have been completed by the home but these must be updated to ensure so far as possible, potential risks are minimised and that staff are regularly briefed and made aware of health and safety issues at all times. The acting manager has since advised the inspector that action has already been taken to attend to these matters. Havengore House DS0000051663.V295838.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x 2 x x x x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 2 Havengore House DS0000051663.V295838.R01.S.doc Version 5.2 Page 21 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 OP7 Regulation 14 & 15 Requirement The Registered Person must ensure that all care plans and risk assessments are maintained consistently & kept under review in sufficient detail, to show the action to be taken by care staff in meeting the health, personal and social needs of residents. (Previous timescale of 15/12/05 not met) The Registered Person must ensure that the premises are suitable for the purpose of achieving the aims and objectives set out in the Statement of Purpose. This includes providing suitable space to allow highly dependent residents to be bathed, with the assistance of staff and any appropriate equipment, which may be required. ( previous timescale of 01/04/06 not met). The Registered Person must have available for inspection full recruitment records including CRB checks for all staff. The Registered Person must DS0000051663.V295838.R01.S.doc Timescale for action 31/07/06 2 OP21 23 31/12/06 3 OP29 17 & 19 Sched. 2 13 & 23 30/06/06 4 OP38 31/07/06 Page 22 Havengore House Version 5.2 ensure that all parts of the home and grounds to which service users have access, are so far as reasonably practicable, secure & free from hazards to their health & safety and any potential risks are minimised .Where necessary, the Fire Officer must be consulted regarding side gate security & fire escape route . 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 Refer to Standard OP3 Good Practice Recommendations The Registered Person should as part of the pre-admission assessment, include background information & a social history for prospective residents. The Registered Person should arrange for updated photo identification to be available for all staff as part of the recruitment records. OP29 Havengore House DS0000051663.V295838.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Havengore House DS0000051663.V295838.R01.S.doc Version 5.2 Page 24 - 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!