Inspection on 27/11/06 for Salvation Army Harbour Recovery Centre (The)

This inspection was carried out on 27th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

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

CARE HOME ADULTS 18-65 Salvation Army Harbour Recovery Centre (The) Riverside House 20 Garford Street London E14 8JG Lead Inspector Anne Chamberlain Unannounced Inspection 27th November 2006 11:15 Salvation Army Harbour Recovery Centre (The) DS0000067862.V320850.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Salvation Army Harbour Recovery Centre (The) DS0000067862.V320850.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Salvation Army Harbour Recovery Centre (The) DS0000067862.V320850.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Salvation Army Harbour Recovery Centre (The) Address Riverside House 20 Garford Street London E14 8JG 020 7538 2097 020 7987 8942 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) The Salvation Army Rita Ann Carol Wooldridge Care Home 8 Category(ies) of Past or present drug dependence (8) registration, with number of places Salvation Army Harbour Recovery Centre (The) DS0000067862.V320850.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: The Harbour Recovery Centre is an 8 bedded unit which is run as a detoxification centre by the Salvation Army. The service is commissioned by the London Borough of Tower Hamlets. They have perceived a need among young Bangladeshi men to detoxify from non-injected heroin and this is the speciality of the unit, although the admission criteria does not exclude nonBangladeshi service users. The detoxification programme lasts between 7 to 16 days when service users will transfer to rehabilitation services to continue their recovery. The unit is next door to another Salvation Army detoxification centre. One manager is registered to manage both services. The Harbour Recovery staffing consists of a team leader and four registered nurses and four project workers. Fees are set at £1210 per week. Salvation Army Harbour Recovery Centre (The) DS0000067862.V320850.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The service opened in August 2006. This is the first inspection under the Care Standards Act 2000 and the aim was to cover all key standards. The inspection was carried out over one short day. The inspector was assisted by the registered manager of the service and the team leader. She spoke to two service users and inspected two service user and two staff files. She also viewed documentation. The inspector toured the premises including the arrangements for the administration of medication. The inspector would like to take this opportunity to thank all who assisted her in the inspection. What the service does well: What has improved since the last inspection? This is the first inspection Salvation Army Harbour Recovery Centre (The) DS0000067862.V320850.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Salvation Army Harbour Recovery Centre (The) DS0000067862.V320850.R01.S.doc Version 5.2 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 Salvation Army Harbour Recovery Centre (The) DS0000067862.V320850.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The project is careful to admit only service users who meet their eligibility criteria and whose needs can be met. EVIDENCE: The service has a clear eligibility criteria. They do not accept referrals for individuals who have major mental health needs, and those who have been sectioned until the mental health act. The service will consider referrals for individuals who have personality disorders or who have had depressive episodes. Because the service caters mainly for younger people the deterioration in physical health associated with long term use of drugs or alcohol is less present. The inspector viewed a sample of referrals to the project. The referral form is comprehensive and when fully completed gives enough assessment information for the service to form a judgement about suitability. Salvation Army Harbour Recovery Centre (The) DS0000067862.V320850.R01.S.doc Version 5.2 Page 9 Once admitted to the project service users undergo further assessment and the inspector viewed on service user files, completed initial assessments. Salvation Army Harbour Recovery Centre (The) DS0000067862.V320850.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of service users are properly assessed. They are encouraged to take decisions which are then supported. Risks are assessed and worked with. EVIDENCE: The inspector viewed care plans on the files of service users. These plans would be part of a larger overall care plan which will have been drawn up by the community worker. Care plans are individual. The team leader explained that one service user, whom the inspector met, had started to withdraw himself from opiate use before he came to the centre. His support needs will therefore differ from that of others and his care plan would reflect this. Salvation Army Harbour Recovery Centre (The) DS0000067862.V320850.R01.S.doc Version 5.2 Page 11 Service users have little say in the design of the detoxification programme and there are necessarily rules and boundaries which are part of it. Their views on issues like food or the comfort of the unit are welcome. The team leader stated that the programme does not rest on group work but on one to one interaction. Thus goal setting and planning for aftercare are discussed quite early in treatment. However the pace of the work is client led. The project has a weekly meeting where service users are encouraged to express their views on the running of the project. The inspector saw evidence of this in the form of minutes. The service users have requested a change in the timing of lunch and dinner, preferring to eat later. They also requested Shiatsu massage. Both requests have been acted upon. The project has accommodated cultural needs supporting the practices of Ramadan and escorting service users to the Mosque on Fridays, when they choose to attend. The team leader stated that following initial assessment generic risk assessment is undertaken. The inspector viewed the form for this. If a risk is identified the care plan incorporates measures to reduce it. The home has identified a high risk of early discharge among the particular client group. In the early months of the project a high proportion of service users have discharged themselves at the onset of withdrawal symptoms. The service has used their policy and procedure for early discharge, giving service users appropriate advice to safeguard them. The inspector viewed the policy and a handout which is given. The team leader stated that they have not yet had to put into practice the missing persons policy. Salvation Army Harbour Recovery Centre (The) DS0000067862.V320850.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users take part in a range of culturally appropriate activities. They use the local community in positive ways. Relationships with family are supported and a healthy diet is offered. EVIDENCE: As previously mentioned group work is not the mainstay of the programme. When the inspector spoke with one service user he said he was surprised about this and the inspector wondered if he had been properly prepared prior to deciding to enter the unit. If so he did not appear to have retained the information (see recommendations). Salvation Army Harbour Recovery Centre (The) DS0000067862.V320850.R01.S.doc Version 5.2 Page 13 The centre runs an art group and the inspector noted attractive paintings by the service users hung on the walls. The art therapist writes reports which the inspector viewed in the service user files. The team leader stated that a number of outside agencies and drug services visit the project to present their services, including the Community Drug Team and HIV and Adults Drug Action (HDA) This is of positive help because the long term rehabilitation of the individual will depend on engagement with community agencies. Service users will be encouraged to enter into further residential rehabilitation or to make use of the day programmes which are available. The inspector met a service user who has a place at a 5 day a week x 12 weeks day programme. The Salvation Army runs a hostel for homeless people in the same building as the recovery project and the team leader stated that 5 service users have transferred to that hostel. The project has set aside a quiet room for private prayer and also for meetings. A prayer mat has been provided. The project has purchased some Bangladeshi board games which are kept in the quiet room and which the inspector saw. Exclusive relationships within the unit are not allowed and service users may not enter each others room. Family visits are allowed after the first four days. Visiting is between certain hours on three days of the week. The team leader stated that a high proportion of the service users are married with young children but so far no children have visited the centre. There is a payphone for the use of service users and they can receive calls there. Mobile phones have to be given up on entry to the unit. Service users confidentiality is maintained and they will be asked Is there anyone you dont want to know you are here?. So far there have been no difficulties with contacts from the community. The daily routine includes three meals a day and as aforementioned service users prefer their dinner later in the evening. Their sleep pattern before coming to the unit would be likely to be rising late and going to bed late. Staff try to strike a balance between accommodating personal preference and imposing a more normal routine. The unit has no garden or access to the open and the team leader stated that staff encourage service users to get out each day for a walk and some fresh air. The project has found that it is necessary to escort service users in the community as drugs are readily available in the local area. Salvation Army Harbour Recovery Centre (The) DS0000067862.V320850.R01.S.doc Version 5.2 Page 14 The project has a doctor, a general practitioner (GP) with a special interest in the psychology of addiction. He calls every weekday for an hour and a half between 12.30p.m. and 2p.m. He sees all the service users. The catering arrangements at the Recovery centre are not yet developed. At the moment the food is being brought across from the project next door and there is a three week set menu, from which service users choose the night before. On Saturdays they have takeaway. One service user told the inspector that the previous Saturday staff but not service users had had a takeaway meal. This was reported to the team leader. One of the service users told the inspector he found the diet rather bland. The team leader said that they do have Asian food stored in the refrigerator but the service users are used to home cooked food and dont seem to fancy preprepared meals. The service users also told the inspector they miss having puddings as these are not provided. The team leader stated that there is always fresh fruit available but agreed to provide some ready made puddings like canned rice and canned custard (see recommendations). The inspector was also told that a chef who will cook Asian food on the premises has been recruited and awaits Criminal Records Bureau (CRB) clearance to start work. The inspector was satisfied that whilst not meeting everyones expectations the service is offering a healthy, nutritious diet and improvements to the present provision are on track. The team leader stated that service users are encouraged to cook together in groups as a therapeutic activity and to gain independence. Salvation Army Harbour Recovery Centre (The) DS0000067862.V320850.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sensitive support of psychological and emotional needs is given. Arrangements for the administration of medication are safe and service users have involvement in the design of their medication plan. EVIDENCE: The project does not offer personal care. Service users are independent in this respect, and all rooms are en-suite. The project does offer psychological and emotional support. Service users have two keyworkers a nurse and a project worker. There are regular one to one keywork sessions. The team leader stated that staff recognise the importance of good assessment of health needs. Mild asthma and the use of inhalers is fairly commonplace but the project has also had service users with more serious health conditions. As Salvation Army Harbour Recovery Centre (The) DS0000067862.V320850.R01.S.doc Version 5.2 Page 16 the use of drugs tends to mask symptoms there is physical and psychological adjustment to be made upon withdrawal. The project has been able to successfully manage medicated withdrawal alongside prescriptions for preexisting medical conditions. There is a GP next door and he calls once a fortnight for physical health needs or is available when needed. Some service users are underweight when they enter the home and high calorie supplements like Ensure are given to them. The inspector viewed the arrangements for the administration of medication. Service users discuss their projected treatment programme with the GP who gives them choices about medication where possible. Information about sideeffects is given. Some service users want to reduce their medication support faster than the programme generally allows. Prescriptions can be FAXED to the pharmacy and delivered the same day. Controlled drugs are recorded when brought into the unit and when returned to the pharmacy. The inspector viewed the book used. Medications are stored in a locked cupboard in the treatment room. The medication folder carries the specimen signatures of the nurses. Each service user has a section with their photograph to identify them. Drugs prescribed by the doctor are recorded on pink sheets. Homely remedies which can be prescribed by a nurse are recorded separately on white sheets. In addition to individual prescribed medication, the service carries stock drugs. Salvation Army Harbour Recovery Centre (The) DS0000067862.V320850.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaints are properly dealt with but recording must be improved. Adults are safeguarded from abuse but all staff need to be familiar with the centres policy. EVIDENCE: The service has a complaints policy and procedure which is outlined in the handbook which all service users are given. The first stage of the process is to complain to the manager who will respond within three days. The team leader stated that he has had two complaints since the service opened. The first service user in the unit complained that he had no company. Another service user complained about the food and the fact that he was not allowed out alone. The team leader stated that he wrote back to both, but has not opened a complaints file and was not able to produce copies of the letters. The manager must ensure that a complaints file is opened. This should contain all complaints correspondence and have a log at the front so that complaints can be monitored and any patterns observed (see requirements). Salvation Army Harbour Recovery Centre (The) DS0000067862.V320850.R01.S.doc Version 5.2 Page 18 The service has a policy and procedure for dealing with allegations of adult abuse. The team leader stated that they had had nothing of this nature to deal with so far. The inspector asked the team leader what steps he would take following an allegation being reported. The team leader was a little unclear as to the order of events and spoke of conducting an investigation before informing social services. The inspector reminded him that social services should take the lead in these cases (although they might well ask him to conduct an investigation) and advised him to familiarise himself with the centres policy and procedure, also that of the local authority. A copy of the local authority policy and procedure must be kept in the office. (see requirements). Salvation Army Harbour Recovery Centre (The) DS0000067862.V320850.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The centre is clean and comfortable but a requirement has been made around heating. EVIDENCE: The inspector toured the centre. It is on the fourth floor and is served by a lift. The other exit is via stairs and the door is alarmed. There are also CCTV cameras trained on the reception area, for the protection of the service users. The unit is bright, clean and modern but is not ideal as there is not really enough space for administration and storage and there is no access to the outside. There is a balcony but this is permanently closed off for the safety of service users. Salvation Army Harbour Recovery Centre (The) DS0000067862.V320850.R01.S.doc Version 5.2 Page 20 There are two kitchens one at either end of the centre. Both have TV and comfortable seating and one has a pool table. Only one kitchen is currently used for cooking and the other is used for laundry. The inspector viewed a typical bedroom and noted that it was comfortable and well fitted out. As previously mentioned the rooms are all en-suite. In addition there is one bathroom. Service users complained to the inspector that the centre was not warm enough. The inspector agreed that the temperature was rather too cool for comfort. The team leader stated that there had been difficulties with the heating and the problem had been reported to the maintenance contractor. He expected it to be resolved quickly (see requirements). The inspector observed the home to be clean and hygienic. As previously mentioned laundry is done in a kitchen which is not used for cooking. There is no foul laundry. The team leader stated that health and control of infection training is undertaken on induction. In addition two staff have undertaken the Tower Hamlets course which covered blood borne diseases. Salvation Army Harbour Recovery Centre (The) DS0000067862.V320850.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35. Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. Staff are competent and are offered appropriate training. Recruitment procedure is safe but must be followed in all cases. EVIDENCE: The team leader explained that they had recruited staff who have had experience in substance misuse or a mental health setting. At interview the panel had been looking for people with a fairly robust personality, clear thinking process and an understanding of the systems they would need to work with. These qualities were tested for with case scenarios. The nurses working at the project are registered mental health or registered general nurses. A service user commented to the inspector that he felt the agency staff do not demonstrate the same commitment as the full time permanent staff. This was reported to the team leader. Salvation Army Harbour Recovery Centre (The) DS0000067862.V320850.R01.S.doc Version 5.2 Page 22 The recruitment procedure at the centre is robust and incorporates equal opportunities. Applicants are given a job description, they complete an application form and are interviewed. Two references are taken up. Successful applicants sign a contract with the service and an ethical statement. They are also given a staff handbook. Criminal records bureau (CRB) checks are taken up. In the meantime individuals who have a current CRB are allowed to start work, but are not ever alone with service users. The inspector viewed two staff files and found that the service had not fully followed its own recruitment procedure. One staff member had had no references taken up (see requirements). The team leader stated that all new staff have a weeks induction which includes health and safety, food handling, fire and first aid. Some staff have attended risk assessment and dual diagnosis training with Tower Hamlets. One nurse is training in acupuncture. The team leader said that it is made clear in supervision that personal development is a pro-active process involving the worker. Staff are asked to plan their development. The team leader stated that he will prepare a training matrix to see at a glance what training individuals have done. The inspector asked him to also put something on the staff file, either a certificate or a sheet of confirmation of the training, so that there is cross reference. Salvation Army Harbour Recovery Centre (The) DS0000067862.V320850.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The project is well run and working practices are safe. Quality control measure have been put in place. EVIDENCE: The team leader explained to the inspector his qualification and the experience he has brought to his role. He has substantial management experience and an in-depth knowledge of substance abuse. The registered manager, team leader and inspector agreed that there are some teething problems and it will take twelve months for the project to settle. Salvation Army Harbour Recovery Centre (The) DS0000067862.V320850.R01.S.doc Version 5.2 Page 24 During that time the gaps in the systems will emerge and there will be adjustments to fill them. The project currently uses the policies and procedures of the detoxification unit next door. These transfer well as the basic work of the units is the same, but differences will emerge and the documents will then be amended. One difference which has already emerged appears to be cultural in that the service users as a group are generally very polite and appreciative of the service they are receiving. The service users are given yellow feedback forms to comment on the project. There is a house meeting each Friday as already mentioned. The team leader has identified two staff members to be responsible for working through the Quality Alcohol and Drugs Service (QUADS) standards. They will do a few each week over the year. The project has a service agreement with the London Borough of Tower Hamlets who fund the beds. The registered manager and team leader felt that this will do for the first year but that the project will then need an annual plan to work with. There will be a review in April 2007. The project is located in a building where the managing agents, part of the Salvation Army, take responsibility for fire protection, water gas and electricity safety. The inspector was therefore not able to inspect records for these. She may ask at the next inspection for the Salvation Army to produce some evidence of safe working practices. The team leader advised that substances hazardous to health are stored in the hostel downstairs. A member of staff brought a cleaning agent into the unit whilst the inspector was there. It might have been for a specific task or might have been her personal shopping. The inspector was assured that in circumstances like this the item would be stored under lock and key. Staff have lockers for their personal possessions. Salvation Army Harbour Recovery Centre (The) DS0000067862.V320850.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x Salvation Army Harbour Recovery Centre (The) DS0000067862.V320850.R01.S.doc Version 5.2 Page 26 NO 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 YA22 Regulation 12 Requirement The manager must ensure that a complaints file is opened. This should contain all complaints correspondence and have a log at the front so that complaints can be monitored and any patterns observed. The manager must ensure that the team leader familiarise himself with the policy and procedure for protecting vulnerable adults from abuse, also that of the local authority. A copy of the local authority policy and procedure must be kept in the office. The manager must ensure that the centre is adequately heated. The manager must ensure that all staff have two satisfactory professional references provided before they start work at the centre. Timescale for action 01/01/07 2. YA23 13(6) 14/12/06 3. 4. YA24 YA34 2 (p) 19 14/12/06 01/01/07 Salvation Army Harbour Recovery Centre (The) DS0000067862.V320850.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA12 YA17 Good Practice Recommendations The manager should speak with referrers to confirm that prospective service users understand the specific set up of the project. The manager should ensure that service users are offered puddings within the present limitations of the catering arrangements. Salvation Army Harbour Recovery Centre (The) DS0000067862.V320850.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection East London Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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 Salvation Army Harbour Recovery Centre (The) DS0000067862.V320850.R01.S.doc Version 5.2 Page 29 - 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. 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