Inspection on 27/01/06 for Little Haven

This inspection was carried out on 27th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Little Haven 01/08/07

Little Haven 30/10/06

Little Haven 31/08/05

Little Haven 01/12/04

Little Haven 06/07/04

Little Haven 02/02/04

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

CARE HOMES FOR OLDER PEOPLE Little Haven 66 Laleham Road Catford London SE6 2HX Lead Inspector Kate Matson Unannounced Inspection 27th January 2006 10:30 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 Little Haven DS0000025598.V281409.R01.S.doc Version 5.1 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. Little Haven DS0000025598.V281409.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Little Haven Address 66 Laleham Road Catford London SE6 2HX 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) 0208 6974246 Elizabeth Peters Care Homes Limited Mr Martin Muriuki Care Home 4 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (0) Little Haven DS0000025598.V281409.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users admitted to the MD category must be between the ages of 55 and 65 years. 31st August 2005 Date of last inspection Brief Description of the Service: Little Haven is a care home for four people who have mental health problems and are aged 55 or over. The home is one of four owned by a local provider, Elizabeth Peters Care Homes Ltd. The home is an older terraced property and is not identifiable as a care home. It is located within a short walking distance of Catford town centre, although there are smaller shops available locally. There are four single rooms over three floors. The home could accommodate a wheelchair user on the ground floor. Little Haven DS0000025598.V281409.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced statutory inspection was conducted over 7 hours. The inspection included discussion with two service users, the new registered manager who is job sharing with the existing manager, a staff member, examination of service users files, staff files and other records. What the service does well: What has improved since the last inspection? What they could do better: Care plans now included the activities that service users wanted to engage in, and although a record of activities had been started, this had not been updated Little Haven DS0000025598.V281409.R01.S.doc Version 5.1 Page 6 to evidence that service users were taking part in as many activities as they wished and a previous requirement is restated in this report. Although service users can exercise choice and autonomy in many areas, a restriction of the kitchen being locked at night is still not supported by a risk assessment indicating why this is necessary. Despite concerns being raised at previous inspections about recruitment practices and in particular checks with the Criminal Records Bureau (CRB) and list of people considered unsuitable to work with vulnerable adults (POVA list), a staff member had started work with an existing CRB check meaning that a check against the POVA list had not been made. A letter of serious concern was sent to the provider following the inspection and the provider supplied evidence that a new request had been submitted and a risk management plan was in place to protect service users. Staff files still did not include all of the required documentation such as proof of identity and photographs in some cases. Although the new manager had completed training records for each staff member a training plan was still not in place to evidence that training met the sector skills council specifications and was based on mandatory requirements and an assessment of staff deficits and service users need. Business and development plans had been provided for some other homes in the group, but a plan was not available for Little Haven to evidence that service users are safeguarded by the accounting and financial procedures of the home. Concerns about the adequacy of staff supervision have been raised at five previous inspections. The new manager has made efforts to increase the level of supervision at the home, and some staff had received supervision twice in a 2-3 month period, however others had no supervision records on file. Enforcement action is now being considered regarding this issue. It was noted that in addition to the issues with staff records, incidents in the home were being recorded as accidents and CSCI was not being notified of accidents and incidents as required. The provider is required to ensure that there is a clear distinction between accidents and other incidents, there is a format for each and that CSCI is notified of all incidents covered under Regulation 37 of the Care Homes Regulations. 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. Little Haven DS0000025598.V281409.R01.S.doc Version 5.1 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 Little Haven DS0000025598.V281409.R01.S.doc Version 5.1 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): 1 Prospective service users have the information they need to make an informed choice about where they live. EVIDENCE: It was found at the previous inspection, that although the statement of purpose and service users guide had been reviewed and both documents now included the required information, the age range to whom care is provided needed to be stated as being 55yrs and over. At this inspection the manager on duty showed the inspector a document that stated this, however other information was missing, though the manager stated she would ensure that the documents include the required information. A statement of purpose was sent to the inspector after the inspection and included the required information. Little Haven DS0000025598.V281409.R01.S.doc Version 5.1 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 and 10 Service users care plans now include all relevant areas. Service users physical and healthcare needs are met. The homes medication practices are safe. Service users were seen to be treated with respect and their right to privacy upheld. EVIDENCE: Three of the service users’ personal files and care plans were examined. The home uses a well-known care planning system. It had been noted at previous inspections that care plans covered only limited areas, which meant that some areas of need would not be addressed. At this inspection it was found that care plans covered all areas that were relevant to each service user, care was regularly reviewed and service users were involved in the process of planning and review. Service users are all registered with one GP, although they may go to another if they wish and they are within the catchment area. Service users with mental health problems are registered on CPA and have regular support from mental health services. Evidence from service user files indicated that they have routine access to chiropodist, dentist and optician. Service users are supported to take responsibility for their health and one service user had been referred to Little Haven DS0000025598.V281409.R01.S.doc Version 5.1 Page 10 a smoking cessation clinic although he had chosen not to go. Service users are supported to eat a healthy diet and are weighed monthly. The medication supply and records were examined. Medication is mainly supplied in blister packs. At the last inspection it was found that these were largely in order though it was noted that one dose of medication had been missed though it was recorded as being given and it was also noted that dietary supplements were not being recorded. This was of concern because it is not possible to know that service users are getting the medications that they need. Also there were no homely remedies available, meaning that service users do not have easy access to medications for minor ailments. It was recommended that the home obtain a copy of the guidance “Administration and control of medicines in care homes and children’s service” produced by the Royal Pharmaceutical Society of Great Britain (RPSGB) in order to improve medication practice. At this inspection it was found that administration of medication matched recording and food supplements were being recorded. Homely remedies were now available with written approval from the GP and a copy of the RPSGB guidance was now available. All service users have their own room. The home has a cordless phone so service users can have telephone conversations in private. Service users are given their mail unopened though one service user requires support in reading his. The inspector observed interactions between staff and service users on the day of the inspection that showed service users are treated with respect. On the day of the inspection a service user was taken into his bedroom to have a physical examination in privacy. Little Haven DS0000025598.V281409.R01.S.doc Version 5.1 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 and 14 Contact with the local community is maintained and although an increase in activities was reported there was little evidence available to support this. Service users exercise control over most aspects of their lives though a restriction in the use of the kitchen is still not supported by a risk assessment to evidence its necessity. EVIDENCE: Previous inspections had found that most of the service users tend to prefer activities in the home such as watching television, playing games, or listening to music rather than organised activities. However organised activities are offered including barbeques and parties at the home in addition to those held at one of the larger homes in the Elizabeth Peters Group. It was positive to note at the last inspection that service users had been offered a holiday and one had enjoyed seven days away from the home. However one of the service users stated that sometimes things “get a bit monotonous” and two service users stated that staff were often too busy to spend time with them. The provider was required to ensure that service users are provided with more opportunities for individual and group activities with staff and that care plans detail time spent on these activities and sufficient staff are provided to cover them. At this inspection the manager stated that group activities were not popular in the home but staffing was sufficient to allow for one to one activity Little Haven DS0000025598.V281409.R01.S.doc Version 5.1 Page 12 being offered where required. However although care plans stated the activities that service users wanted to engage in, and although a record of activities had been started, this had not been updated to evidence that service users were taking part in as many activities as they wished. One service user regularly goes out into the local community alone and visits shops, cafes, pubs and parks. Other service users are supported in the community and one service user enjoys visiting the betting shop with support. Service users visitors are welcomed at any time. It was clear that service users make their own decisions in most areas including daily routines, and activities they take part in. Service users are supported to be as independent as possible in managing their financial affairs. Service users are able to bring their own possessions into the home and the newest service user had brought several items of furniture. At the last inspection it was found that the kitchen was locked at night but there was no risk assessment to explain the necessity for this. At this inspection this had not been provided and must be addressed, as any restrictions on service users must be fully evidenced and documented in the service users guide. Little Haven DS0000025598.V281409.R01.S.doc Version 5.1 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): 18 Policies and procedures at the home largely protect service users from abuse though recruitment practice places them at risk. EVIDENCE: At the last inspection it was found that the home had appropriate policies and procedures in place to protect service users from abuse. The registered provider confirmed that most staff had now completed training in adult protection. However, the home’s recruitment practices potentially placed service users at risk of abuse and this situation continued at this inspection and is discussed further under Standard 29. Little Haven DS0000025598.V281409.R01.S.doc Version 5.1 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): 24 and 26 Service users were content with their bedrooms. The home is clean and hygienic. EVIDENCE: At the last inspection it was found that although the home was generally well maintained and that service users were content with their bedrooms, one carpet was in need of cleaning or replacement. At this inspection it was found that the carpet had been replaced. Previous inspections had noted that the washing machine was located in the kitchen and the provider was required to request the environmental health department to approve this. A letter from the environmental health department was provided approving the position of the washing machine provided that no one in the home is incontinent and provided the machine is not used when food is being prepared. At this inspection the manager confirmed that soiled laundry is taken away from the home and normal laundry is not done when food is being prepared. The home was clean including the edges of the kitchen floor and the cooker, which were dirty at the last inspection. Little Haven DS0000025598.V281409.R01.S.doc Version 5.1 Page 15 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 and 30 The numbers and skill mix of staff on duty are sufficient to meet the needs of service users. The homes recruitment practices continue to place service users at risk of abuse. Although most staff have completed appropriate qualifications there is no evidence available to show that the home’s training meets the needs of service users. EVIDENCE: At previous inspections, a duty rota was not available to inspect to ensure that sufficient staff were on duty and at the last inspection rotas were available; however, they did not accurately reflect the situation in the home at the time, they did not show the manager on the rota or any staff working at night and they showed that only one staff was on duty after 5pm and at the weekends, instead of the two until 8pm, every day as previously stated. A letter of serious concern was sent to the provider immediately after the inspection regarding this. At this inspection a duty rota was available that accurately reflected the situation in the home, at the time, it included day and night duty and there were two staff members on duty until 8pm every day. Service users confirmed this. It was noted at previous inspections that staff were allowed to commence employment before appropriate checks had been received from the Criminal Records Bureau (CRB), and not all the staff working in the home had staff files including required documentation available for inspection. At this inspection although files were available on all staff members some again lacked required documents. Out of the eight files examined, one had no photograph or proof of identity. One had only one reference and one had no references. Continued Little Haven DS0000025598.V281409.R01.S.doc Version 5.1 Page 16 failure to comply with this requirement will lead to enforcement action being considered. Three existing staff did not have a CRB check on file and the registered provider was required at the last inspection to more actively pursue these checks. One new member of staff had started work with an existing CRB check meaning that a new check had not been made against the list of people considered unsuitable of working with vulnerable adults (POVA). At the last inspection a serious letter of concern was sent to the provider because a staff member had not had a POVA check done and the risk to service users was clarified. Continued failure to comply will lead to enforcement action being considered. A letter of serious concern was again sent to the provider following this inspection about this. It was also noted that none of the files included evidence of an interview in accordance with equal opportunities policies and the provider is required to provide this. It was noted at previous inspections that a range of training was undertaken, and a good number of staff had completed qualifications to national minimum standards. However there was no training plan available based on mandatory requirements, the needs of staff and the needs of service users, or evidence that the homes training met the National Training Organisation’s (NTO) workforce training targets. The registered provider was required to produce a training plan and ensure that it was. At this inspection there was no training plan, the overall record of training completed was not up to date and there was no evidence available that induction and foundation training were to NTO specifications. Continued failure to comply will lead to enforcement action being considered. However individual training records had been completed for each staff member, though it is recommended that an overall record is kept up to date to allow anyone inspecting the records to see at a glance what training has been completed in the home overall. Little Haven DS0000025598.V281409.R01.S.doc Version 5.1 Page 17 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, 34, 35, 36, 37 and 38 A second manager has been appointed on a job share basis though the existing manager has not yet started one of the qualifications required to ensure that the home is appropriately managed. Service users are consulted regularly about the care they receive. A business and financial plan is still not available to evidence that service users are safeguarded by the accounting and financial procedures of the home. Although the new manager has made efforts to increase the level of supervision at the home, some staff had still not had adequate supervision. Staff files and recording and reporting of accidents and incidents do not safeguard service users rights and best interests. The health safety and welfare of service users are largely protected though evidence of the safety of the electrical installation of the premises is still overdue. EVIDENCE: At the last inspection it was noted that the manager’s name was not on the rota though the inspectors were informed that he usually worked around three days per week. However, when service users were asked how often they saw Little Haven DS0000025598.V281409.R01.S.doc Version 5.1 Page 18 Martin, some did not know who he was and none knew that he was the manager of the home. This was of serious concern and the registered provider was required to address the issue as a matter of urgency and ensure that the home has a manager, who is fit to do the job and is able to work at the home on a full time basis. Following the last inspection the provider appointed another manager at the home on a job share basis. Both managers are now registered. They have clear responsibilities for different areas of management. The new manager who was a senior carer at another Elizabeth Peters Care Home is doing NVQ level 4 in management and care. The other manager had managed Little Haven for four years and is currently completing the NVQ level 4 Registered Managers Award, though has yet to commence a care qualification. The registered provider must ensure that both managers are working towards having appropriate qualifications in management and care. Previous inspections had noted that although the registered provider carried out monthly monitoring visits to the home, reports were not always completed and kept at the home and reports were not sent to CSCI. Following the last inspection four reports for the preceding months had been sent to CSCI and were kept at the home. At the last inspection it was found that quality assurance surveys continued to be completed and the results of the latest surveys were summarised in the service user guide. However it was noted that although the home used a different form for visiting professionals, the same form was given to service users and their relatives. It was recommended that separate survey forms be developed for service users and relatives to reflect their different needs. At this inspection it was found that another survey had been completed though the recommendation had not been implemented. Although evidence was seen at previous inspections that the home’s insurance was adequate and that the home is financially viable, a business and financial plan, including an annual development plan was required. Plans had been seen at other homes in the group, since the last inspection but there was not one available at the home for Little Haven. Continued failure to comply will lead to enforcement action being considered. One service user is completely independent in managing his money. Another has support in visiting the bank but manages his own money in between. The third service user requires support mainly due to his physical health. The records of transactions completed on behalf of this service user were examined. These were all in order and receipts were kept. The small amount of money managed by the home is kept in a locked filing cabinet. Previous inspections had found that although there was some evidence of staff supervision and appraisal in staff files, it did not show that staff were being supervised at least six times per year as required. At this inspection the new manager had made efforts to address this in that four staff had been supervised recently and three of those had been supervised two or three months previously, however three staff had no supervision on file and one had not been supervised for 18 months. This requirement has remained in place over several inspections and enforcement action is now being considered. Little Haven DS0000025598.V281409.R01.S.doc Version 5.1 Page 19 Some of the records required by regulation to be kept by the home were examined including service users records, medication administration, complaints, staff files, service users money, and record of fire drills and were found to be up to date and accurate, unless commented on specifically in other areas of this report. At previous inspections requirements were made that the registered provider must ensure that the home is registered with the Information Commissioner’s Office for the storage of confidential information and that all staff files contain proof of identity and a recent photograph. At an inspection of another of the Elizabeth Peters homes, evidence was available that the home is registered to store confidential information however it is recommended that a copy of this evidence be kept in each of the homes. As already stated under Standard 29 staff files did not all include proof of identity and photographs and the requirement remains unmet. Continued failure to comply will lead to enforcement action being considered. It was also noted that accident forms were used for recording other incidents in the home, that were not accidents and that notifications of these were not sent to CSCI. The registered provider must ensure; there is a clear distinction between accidents and other incidents, there is a format for each and that CSCI is notified of all incidents covered under Regulation 37. Evidence of measures taken to protect the health, safety and welfare of service users was available at the inspection for example, testing of fire alarm, fire equipment, and a satisfactory food hygiene inspection. All staff have undergone food hygiene training and there is always a first aider on duty. Fire drills were held appropriately and the time of drill was now recorded as required at the last inspection. A certificate for the portable electrical appliances was available and a certificate of gas safety was sent to the inspector after the inspection however although the provider was required to provide evidence of testing of the electrical installation of the building at the previous two inspections evidence was not available to support this. Continued failure to comply will lead to enforcement action being considered. It was noted that the file of health and safety information and maintenance certificates was not sectioned or well laid out and old information was mixed up with new. It is recommended that an audit of the file be undertaken to ensure that information can be accessed easily. Little Haven DS0000025598.V281409.R01.S.doc Version 5.1 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 3 X X X X X 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 1 13 3 14 2 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 1 X X X X X 3 X 3 STAFFING Standard No Score 27 3 28 X 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 1 3 1 1 2 Little Haven DS0000025598.V281409.R01.S.doc Version 5.1 Page 21 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. Standard OP12 Regulation 16(2)(m) (n) Requirement The registered provider must ensure that service users are provided with more opportunities for individual and group activity with staff and care plans detail time spent on these activities and provide sufficient staff to cover them. (Previous timescale of 30/11/05 not met) The registered provider must ensure that the need for any restrictions in the home is regularly reviewed and written evidence provided. (Previous timescale of 30/11/05 not met) The registered provider must ensure that no new staff commence employment in the home until a satisfactory CRB disclosure has been received. (Previous timescales of 31/08/04 and 31/01/05 and 31/08/05 not met) The registered provider must ensure that no staff commence work in the home until satisfactory checks have been DS0000025598.V281409.R01.S.doc Timescale for action 30/04/06 2. OP14 17(1)(a) Sch3 (3) q) 30/04/06 3. OP29 19(1)(b) 27/01/06 4. OP29 19(1)(b) 27/01/06 Little Haven Version 5.1 Page 22 5. OP29 17(2) 6. OP29 19(1)(b) 7. OP29 19 (1) (b) 8. OP30 18 (1)(c)(i) 9. OP31 9 (2) (b) (i) 10. OP34 24 and 25 made with CRB and the POVA list. A risk assessment must be conducted regarding the staff member who has not yet received these checks back and sent to CSCI Southwark office. (Previous timescale of 31/08/05 not met though risk assessment was received) The registered provider must ensure that staff records listed in schedule 4 are kept at the home and evidence of information listed under schedule 2 is available for inspection. (Previous timescale of 31/01/05 and 31/10/05 not met) The registered provider must more actively pursue outstanding CRB checks and submit a new application where necessary. (Previous timescale of 30/09/05 not met) The registered provider must make application for a new CRB and POVA check without delay and conduct a risk assessment as to the suitability of the new staff member to continue working at the home until the receipt of these documents. The registered provider must ensure that the homes training and development programme meets the NTO workforce training targets. (Previous timescales of 31/10/04, 31/03/05 and 31/12/05 not met) The registered provider must ensure that both managers are working towards having appropriate qualifications in management and care. The registered provider must DS0000025598.V281409.R01.S.doc 31/03/06 31/03/06 03/02/06 31/12/05 30/04/06 30/04/06 Page 23 Little Haven Version 5.1 11. OP36 18(2) 12. OP37 19(1(b) i) 17(2 13. OP37 17 (2) Sch 4 and 37 14. OP38 23(2(b 23(2(c ensure that there is a business and financial plan for the home including an annual development plan reflecting aims and outcomes for service users. (Previous timescales of 31/10/04 31/01/05 and 30/11/05 not met) Formal staff supervision must be increased to a minimum of six times a year. (Previous timescales of 01/01/03, 31/03/04, 31/10/04, 31/03/05 and 30/11/05 not met) The registered provider must ensure that all staff files contain proof of identity and a recent photograph. (Previous timescales of 31/10/04, 31/01/05 and 31/10/05 not met) The registered provider must ensure; there is a clear distinction between accidents and other incidents, there is a format for each and that CSCI is notified of all incidents covered under Regulation 37. The registered provider must ensure that copies of safety certificates for gas, electrical installation and portable electrical appliances are sent to CSCI, Southwark Office on receipt of the draft report. (Previous timescales of 31/12/04 and 30/09/05 not met though evidence of gas safety and portable electrical appliance testing seen at this inspection - electrical installation still outstanding) 30/11/05 31/10/05 31/03/06 28/02/06 Little Haven DS0000025598.V281409.R01.S.doc Version 5.1 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP29 OP33 OP37 OP38 Good Practice Recommendations It is recommended that records of interviews be kept on staff files to evidence that interviews are conducted in accordance with equal opportunities policies. It is recommended that separate survey forms be developed for service users and relatives to reflect their different needs. It is recommended that evidence that the home is registered for the storage of confidential information is kept at the home. It is recommended that an audit of the health and safety information and maintenance certificates file be undertaken to ensure that information can be accessed easily. Little Haven DS0000025598.V281409.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 Little Haven DS0000025598.V281409.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!