Inspection on 28/09/05 for Hazeldene

This inspection was carried out on 28th September 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

Hazeldene 31/07/06

Hazeldene 12/01/06

Hazeldene 28/02/05

Hazeldene 06/09/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Hazeldene 1 Dunbar Avenue Norbury London SW16 4SB Lead Inspector Claire Taylor Unannounced Inspection 28th September 2005 10:00 Hazeldene DS0000028107.V253304.R01.S.doc Version 5.0 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 Hazeldene DS0000028107.V253304.R01.S.doc Version 5.0 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. Hazeldene DS0000028107.V253304.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hazeldene Address 1 Dunbar Avenue Norbury London SW16 4SB 020 8679 1462 020 8679 1462 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 Jacob Lee Mr Jacob Lee Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Hazeldene DS0000028107.V253304.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28 February 2005 Brief Description of the Service: Hazeldene is a five bedded small care home registered with the Commission for Social Care Inspection to cater for young adults with a learning disability. Situated in a residential street in Norbury, the home is well placed for public transport links to local amenities and shopping. There are five single bedrooms with one located on the ground floor. Communal areas consist of a spacious lounge, dining area and rear garden with paved area. Sufficient numbers of bathroom and toilet facilities are located near service users bedrooms and communal areas. The proprietor of the home, Mr Cliff Lee, is also the registered manager for the home and works most days. Hazeldene DS0000028107.V253304.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that began at 10.00am and lasted seven hours. Three service users spoke with the inspector, one of whom had only moved in within the last two weeks. Two staff members were on duty and the registered manager / provider, Mr Cliff Lee, facilitated the inspection process. Records were examined including the service users’ plans of care; staff files and other records related to the general management of the home. A brief tour of the premises took place and two service users kindly showed the inspector their bedrooms. All those involved are thanked for their cooperation and the service users and staff for the hospitality shown throughout the inspection process. Pre inspection comment cards provided by the Commission for service users and relatives were not returned on this occasion although one was received from a professional associated with the home that gave positive feedback. What the service does well: Hazeldene continues to be an efficiently run home, where the health, personal, social and emotional needs of the service users are well met. Three service users spoken to gave positive comments about the staff, activities and meals and appeared relaxed and comfortable in their home. Planning and review of care is thorough and helps the service users build upon and develop their independence as far as possible. Care plans are clearly recorded, highlight achievements and progress and are routinely shared with the service users involved. Service users have their privacy respected; are treated with respect and are consulted about the things they want such as leisure activities and meals. Management of the home appeared to be very well ordered with the benefit of a stable staff team that remains largely unchanged. The home has good systems in place to make sure that staff have the necessary training and skills to support the service users and meet their current needs. The manager retains good communication links with the service users’ relatives and representatives. The home is well maintained, homely and decorated to a high standard. The owner/ manager and the staff team continue to demonstrate a commitment towards maintaining and improving standards of care. Likewise, the home shows consistency in its compliance with the National Minimum Standards and Regulations. Hazeldene DS0000028107.V253304.R01.S.doc Version 5.0 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. Hazeldene DS0000028107.V253304.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hazeldene DS0000028107.V253304.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 4 Information passed to prospective service users is good and service users have had the opportunity to visit the home, stay overnight and meet the other service users and staff before deciding to move into the home. The home has its own assessment plan to ensure that any new service user’s needs are fully assessed prior to their admission and that staff are aware of how to support them. EVIDENCE: A specific form is used on which to record an overall assessment of each service user once they have been admitted. This covers all aspects of the person’s life, including strengths, social and cultural needs and psychological needs. Copies of these assessments were on file for each service user as well as detailed needs assessments completed by their placing authorities. I.e. undertaken by their care managers. This provides staff with comprehensive information about a person’s needs and how they should be supported. A comprehensive needs assessment was available for the service user who had recently moved to the home. There was also good evidence that the service user had received appropriate support to settle in to the home. The service user confirmed that they visited the home to look round and meet everyone before they moved in. Hazeldene DS0000028107.V253304.R01.S.doc Version 5.0 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 the following standard(s): 6,7 and 9 The care planning process is managed to a good standard. Individual plans of care are reviewed and revised regularly and service users are fully involved. Choice and decision making for service users is promoted enabling their involvement and opportunities to contribute to the operation of the home. To enhance the service users’ independence, effective support is provided within a risk management framework although some individual plans need reviewing. EVIDENCE: Clear plans were in place that identifies how the service users are supported to achieve their personal aspirations and goals. The manager had developed a comprehensive personal file for the newly admitted service user. This is good as it provides staff with important information on how to support the person’s needs. Records also showed that this service user’s needs were being closely monitored to ensure that the home could continue to meet them. A planned review meeting had been booked too. The service users’ key workers keep the plans up to date and involve the service user at each stage. Main reviews involving the service user’s care manager occur every year. The home should hold a formal review meeting every six months however involving the service user, relative(s) and any other significant professionals. An overall review of Hazeldene DS0000028107.V253304.R01.S.doc Version 5.0 Page 10 needs and plans of care should be discussed and minuted. There are formalised opportunities for service users to participate in group discussions/ meetings about the operation of the home. Minutes of service users meetings are regularly held and discussions are geared towards their views. E.g. choice of activities and menus. Service users are supported to take ‘responsible’ risks as appropriate whilst promoting independence. A risk assessment tells the people that support the service user if there are activities that a person undertakes, or things that might happen, that put them at risk of being harmed. Assessments also tell staff about what they can do to try to prevent a service user from being harmed. Risk plans cover a variety of situations from accessing community activities, travelling independently and learning skills within the home. For one service user, the manager reported that there had been a change in their behaviour pattern and one incident of physical aggression towards staff. The risk plan had not been reviewed to reflect such changes and this must be addressed. Hazeldene DS0000028107.V253304.R01.S.doc Version 5.0 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 the following standard(s): 12, 13, 15, 16 and 17 Service users have the opportunity for self-development, are part of the local community and are supported to continue education and appropriate activities, so that they can maximise fulfilment and achievement in their lives. Appropriate contact between service users and their families and friends is encouraged to help them maintain relationships. EVIDENCE: The home enables good links between service users, their family and friends and the local community. Social needs are clearly described within individual care plans that take account of service users preferences and enable them to have the opportunity to take part in worthwhile and meaningful activities. Three of the home’s service users were out at their respective day centres and work places. Two are in paid employment at Crossfield Link centre where they participate in jobs such as printing, domestic tasks and canteen duties. The other two were in the home and spoke about the activities. One service user was looking forward to a planned barbecue at the weekend and also talked about his recent holiday. The other service user had only just moved to the home and staff were in the process of supporting her to develop a programme of her preferred activities. Information about further educational courses is Hazeldene DS0000028107.V253304.R01.S.doc Version 5.0 Page 12 made available to the service users and one person recently undertook a pottery class. Visitors are welcomed and staff support service users to visit and spend time with their respective families at home. There are opportunities for service users to socialise with friends and meet people through a range of community activities, including a weekly social club. Service users take part in domestic tasks around the home and are encouraged to take responsibility for the upkeep of their bedrooms with support from staff as needed. E.g. hoovering, dusting and personal laundry chores. The care plans make clear reference to these daily tasks and how the service users are supported to do them. As required at the last inspection, service users respective choices regarding the provision of a door key has been recorded in their individual plans. The menus are written in conjunction with the service users and discussions about food choices are recorded at service user meetings. There is a varied choice of two meals that represents a range of tastes and cultural and personal preferences. Service users sign a menu sheet to indicate their daily meal choices. Main household shopping is done once a month and staff also support service users to shop for day-to-day general provisions as needed. Service users are able to eat at flexible times according to their routines and social lives and are actively encouraged to be involved in the preparation of meals. Snacks and drinks are available at all times. Nutritional monitoring and dietician support occur where required. Guidelines on the correct preparation of food and a clear risk assessment were in place for one service user who can be at risk of choking. Hazeldene DS0000028107.V253304.R01.S.doc Version 5.0 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 the following standard(s): 18, 19 and 20 Personal care is carried out in a way that service users prefer so that dignity and choice are maintained. Promotion of health is well observed. Service users welfare is closely monitored to ensure that their physical and emotional needs are met. Medication is well managed to maximise good health although staff need to attend proper accredited training in dealing with medicines. EVIDENCE: Individual care plans for service users clearly identify any guidelines or goal plans relating to personal care. Staff were observed to support service users in a dignified and courteous manner and respect their privacy. Each service user has a nominated key staff who support individuals to shop for clothes and personal toiletries and to visit local hairdressers. All service users are able to access additional or specialist support as needed through a referral process. One service user has physiotherapy visits on a regular basis. In addition, an occupational therapy assessment had been completed and a walker frame has been provided to aid mobility for this person. Service users are supported to access services with other professionals such as Dentist, Optician, Chiropody, and Consultant Psychiatrist. Pending appointments are also kept in the house diary. All service users are offered annual health checks and care plans contained such details. Medication is supplied in a blister pack from a local pharmacy and is kept securely in a locked cabinet in the laundry area. Hazeldene DS0000028107.V253304.R01.S.doc Version 5.0 Page 14 A list of all staff authorised to sign for medication is maintained and administration sheets were signed and up to date. Just two of the current service users are prescribed regular medication and the registered manager / provider advised that no service users are able to self-administer at present. As previously required, the home has developed a homely remedies policy which has been approved by the G.P. Domestic medication such as painkillers is now available for the service users should they need it. The manager provides medication training for staff in the home. As a further safeguard to maximising safe practice, staff need to be trained by an approved pharmacist or complete an accredited medication course. Hazeldene DS0000028107.V253304.R01.S.doc Version 5.0 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 the following standard(s): 22 and 23 Arrangements for complaints and protection from abuse are well managed and ensure that service users feel listened to and safe. EVIDENCE: A clear complaints procedure is included in the service users guide and conspicuously displayed in the home. The version has been formatted with symbols and pictures to make it more accessible to those service users who cannot read. Service users spoken to were clear about who they would speak to if they felt unhappy. Informal concerns raised by service users are addressed through discussion with staff on a day- to- day basis and at regular service user meetings. A log of complaints is kept in a book and since the last inspection; there have been no complaints. There are systems in place regarding the protection of vulnerable adults and relevant policies to safeguard the service users welfare. E.g. management of finances, dealing with aggression and conflict and a whistle blowing policy to state what action to take should staff suspect anything untoward. Records confirmed that any new staff are properly inducted on abuse awareness. Two members of the current staff team have attended formal training on adult protection through the Local Authority and there are plans for the other staff to attend. Service users’ financial records were found to be in good order and receipts are kept in respect of all the financial transactions taken on their behalves. Hazeldene DS0000028107.V253304.R01.S.doc Version 5.0 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 the following standard(s): 24, 26 and 30 Hazeldene is furnished and decorated to a high standard. This provides the service users with comfortable surroundings to meet their needs and emotional well-being. Bedrooms are designed and furnished to meet the personal preferences and individual lifestyles of the service users. The home is clean, hygienic and in a good state of repair which enables service users to live in a safe environment. EVIDENCE: The premises, as at previous inspections, appeared tidy and in a good state of repair and gives the impression of a clean and hygienic home. Further home improvements have been carried out including the redecoration of the hall and stairway. Some bedrooms were viewed with the permission of the service users concerned. The newly admitted service user confirmed that they were able to furnish their room with their chosen possessions and said that they were happy with the room. As required at the last inspection, a fire safety inspection has been carried out by the London fire and emergency planning authority. The registered provider had addressed all of the requirements set including provision of suitable fire door closures and a fire risk assessment. Good standards of hygiene practice are well observed and the home appeared clean and free from odour. Hazeldene DS0000028107.V253304.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Overall, recruitment practices are securely managed to maximise protection for the service users although new CRB checks must be obtained for any new employees. EVIDENCE: The owner/manager works most days and is available on call in the event of an emergency. Four other care staff are employed at the home and there were two vacant posts at the time of this visit. Allocation of staff allows for one to two per shift with extra staff deployed according to service users needs and activities. At night, there is one member of staff on sleep-in duty. Care staff and the manager undertake ancillary duties such as cleaning and cooking. Regular staff meetings are held on a monthly basis and in depth consultations about the home’s care practices and service users needs are routinely discussed. Service users spoken to gave positive views about the staff team and the manager. All staff members receive induction that is linked to the TOPSS specifications. The induction is detailed and linked to the home’s aims and service users’ needs and individual plans. The newest employee’s file showed that orientation to the home had been followed according to scheduled timescales with suitable training provided i.e. health and safety, first aid, manual handling and abuse awareness. Staff records seen gave indication that good standards of care and training organisation are in place at the home. Individual training needs are Hazeldene DS0000028107.V253304.R01.S.doc Version 5.0 Page 18 addressed through supervision and appraisal with records kept of courses attended. The provider explained that the majority of training is accessed through the National Care Homes Association. Staff files sampled were well organised and mostly contained all the required documentation to evidence their fitness to work with this service user group as well as training certificates. All new staff who commence work in the home undergo a thorough vetting procedure to ensure that they are fit to work with vulnerable adults. Since the last inspection the home has employed one new member of staff; the file contained the majority of required checks including a completed job application, the terms and conditions of their employment, two references, proof of identity and a CRB disclosure/POVA check. The CRB check however had been completed by the staff’s previous employer and such checks are not transferable. The registered manager must therefore ensure that an up to date CRB and POVA check for any future employees is obtained before they commence work. Hazeldene DS0000028107.V253304.R01.S.doc Version 5.0 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The manager has good experience and professional qualifications relevant to managing the home. The home’s quality assurance system could be improved upon to ensure that quality of care is regularly appraised and the home is meeting its objectives. Overall, health and safety practices are well observed to ensure that service users live in a safe environment. Record keeping could be slightly improved upon however. EVIDENCE: The owner/ manager has been managing care homes for several years and has now completed the NVQ level four management qualification. Mr Lee has clearly acquired significant experience in caring for people with learning disabilities and gained appropriate skills and knowledge to manage a care home effectively. A ‘residents satisfaction survey’ is offered on an annual basis and had been completed in January of this year. Feedback indicated highly complimentary views about the home and the care provided. As previously recommended, questionnaires have yet to be offered to families and /or representatives and other professionals and this should now be addressed. The Hazeldene DS0000028107.V253304.R01.S.doc Version 5.0 Page 20 owner explained that a formal quality assurance plan for the home was still to be drawn up and implemented. The former requirement therefore remains. The development of such systems should increase confidence that the views of the service users, their relatives and other interested parties influence the running of the home. Accurate records are kept for accident and incident reporting although the home must ensure that the Commission is notified of any events that are reportable under Regulation 37 of the Care Standards Act. This was in relation to an incident of physical aggression concerning one service user and the manager. Regulation 37 was discussed with the manager and a notification form provided. Fire drills, fire equipment and hot water temperature checks are carried out at appropriate intervals. Certificates to evidence the carrying out of water tests, electrical appliances, and electrical and gas safety tests were not checked at this inspection. Health and safety practices are generally well observed to maximise safety for the people who live and work in the home. Risk assessments covering safe working practices have been completed for the premises although as previously identified, they still need to be expanded upon to clearly identify what action or measures are in place to minimise risks. This issue had also been raised during a recent environmental health visit to the home. Aside from this, the home was found to be safe, and the welfare of service users and staff promoted. Hazeldene DS0000028107.V253304.R01.S.doc Version 5.0 Page 21 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 X 3 X 3 X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X 3 X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 2 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Hazeldene Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X 2 X DS0000028107.V253304.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard 9 20 Regulation 13(4)(6) 17(3a) 13(2) 18(1) Sch.2 (4) 17(2), 19 (1)(b,c) Requirement Risk plans must be reviewed at regular intervals or as and when a service user’s needs change. All staff must receive accredited medication training with records to evidence this kept in the home. The registered provider must ensure that they obtain an up to date CRB and POVA check for new staff before they commence employment. A written annual quality assurance development plan needs to be developed for the home. (Requirement outstanding from 31.10.04) Risk assessments concerning safe working practices must be more detailed to clearly outline what measures are in place to reduce identified risks. (Requirement outstanding from 31.11.04) All accidents and incidents must be reported in accordance with regulation 37 of the Care standards act. (Requirement outstanding from 28.2.05) DS0000028107.V253304.R01.S.doc Timescale for action 31/10/05 31/01/06 3. 34 30/11/05 4. 39 24 30/11/05 5. 42 13(4) 15(1) Sch.3,3q 30/11/05 6. 42 37 26/09/05 Hazeldene Version 5.0 Page 23 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 6 Good Practice Recommendations The home should hold a formal review meeting every six months involving the service user, relative(s) and any other significant professionals. An overall review of needs and plans of care should be discussed and minuted. The views of family members, friends / representatives and other interested parties should be sought to ensure the home is meeting its aims, objectives and statement of purpose. (Outstanding from inspection 28.2.05) 2. 39 Hazeldene DS0000028107.V253304.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Hazeldene DS0000028107.V253304.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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