Inspection on 10/04/06 for Sitara Haven

This inspection was carried out on 10th April 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sitara Haven 18/07/07

Sitara Haven 12/09/06

Sitara Haven 30/09/05

Sitara Haven 12/04/05

Sitara Haven 26/08/04

Sitara Haven 13/04/04

Sitara Haven 18/12/03

Sitara Haven 03/07/03

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 Sitara Haven 23 Hambrough Road Southall Middlesex UB1 1HZ Lead Inspector Ms Jane Collisson Unannounced Inspection 10th April 2006 12:05 Sitara Haven DS0000027715.V286672.R01.S.doc Version 5.1 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 Sitara Haven DS0000027715.V286672.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 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. Sitara Haven DS0000027715.V286672.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Sitara Haven Address 23 Hambrough Road Southall Middlesex UB1 1HZ 0208 867 9590 0208 893 5342 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Rajinder Hunjan Mrs Rajinder Hunjan Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Sitara Haven DS0000027715.V286672.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named service user, who has been diagnosed as having a mental illness, remains living in the home for as long as there is no deterioration which affects the well being of other service users, as agreed by the Commission For Social Care Inspection, on 1st December 2005 The home must inform CSCI when the service user no longer resides at the home. 30th September 2005 Date of last inspection Brief Description of the Service: Sitara Haven is a terraced house, located in a quiet residential street close to the shops and amenities of Southall. There are bus services close by and Southall Station is within walking distance. The home is registered for three service users with learning disabilities. It is owned and managed by Mrs. Rajinder Hunjan. She and her family live on the premises. There are three bedrooms for the service users, one on the ground floor and two on the first floor. There is one bathroom with a shower and toilet on the ground floor, and a bathroom with a toilet on the first floor. The two lounges on the ground floor are shared with the owner’s family. One, which has a dining room, overlooks the garden. The other is situated in an interior room, without windows, on the ground floor. Both have comfortable seating and televisions. The kitchen and office are located on the ground floor. There is a small, lawned garden to the rear which is accessed by steps. The current staff team comprises of the Registered Provider/Manager and three support staff. As well as providing permanent accommodation for up to three service users, the home currently has two day service clients and provides respite care at weekends when the permanent places are not filled. Sitara Haven DS0000027715.V286672.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on the 10th April 2006 from 12.05pm to 3.45pm. The inspection process took at total of six hours. One service user and one member of staff were present. The Registered Provider/Manager returned to the home after an hour and the second permanent service user returned in late afternoon from his day centre. Since the last inspection in September 2005, an additional visit was made to the home on the 13th March 2006 to discuss the progress of the requirements and a concern which had been raised. The home currently has two permanent service users and one respite service user who stays in the home for one weekend a month. The Registered Provider/Manager also provides a day service for two service users for part of the week. All of the current service users are men. Fourteen requirements were made at the inspection in September 2005 and a further requirement was made at the additional visit in March 2006. While the Registered Provider/Manager has complied with the majority of these, one is repeated and a further thirteen requirements have been made at this inspection. What the service does well: What has improved since the last inspection? What they could do better: For the last two service users admitted to the home, the referral and assessment procedures have not been followed in sufficient depth to ascertain that the home is suitable to meet their needs. A variation has been granted for a service user to remain in the home, outside of the home’s category, but the Registered Provider/Manager needs to demonstrate that the service user’s needs are being met by the staff and with the appropriate professional Sitara Haven DS0000027715.V286672.R01.S.doc Version 5.1 Page 6 support. This is of particular concern, as the service user had not had the professional support required on a regular basis. While this has been due in part to the health service not providing regular visits, it was not demonstrated that sufficient action has been taken to remedy this. The care plans and risk assessments have not been kept up-to-date to reflect the needs of the service users, or reviewed on a regular basis and amended when needs have changed. There is no evidence that consultation has taken place with service users and their representatives with regard to the content of these. Although there are only two service users who require support with their medication, there have been errors in the medication stock and administration at each visit to the home. The Registered Provider/Manager must ensure that that the service users’ medication stock is regularly checked to ensure it is administered correctly and the records of administration must be maintained for inspection. Improvements have been made to the way in which the service users’ financial transactions are being recorded. However, it was found that the Registered Provider/Manager was holding a Personal Identification Number on behalf of a service user. She must ensure that any financial transactions are in accordance with the rules of the bank of building society so that the service user’s finances are protected. The permanent service users have to share the communal facilities of the home with the Registered Provider/Manager’s family and, for up to three days a week, with clients using the home for day services and respite. The Registered Provider/Manager needs to keep this under review to ensure that the service users are able to use the communal areas as they wish to do. Discussion should be seen to take place on a regular basis regarding the communal spaces available, and a more thorough review carried out if a third, permanent service user is admitted. Because two of the staff live on the premises, the arrangements for covering the waking night duty mean that some long shifts are worked and the night shift changes in the early hours of the morning. The staffing levels must be kept under review to ensure that sufficient staff are employed to cover the rota so that the health and safety of the staff and service users is not put at risk. Improvements are still required to the general management of the home and the way in which records are maintained. In particular, the records are required to be seen to be maintained in good order, be up-to-date and be seen to be amended when reviews have taken place or changes have occurred in the support required. The Registered Provider/Manager is still required to demonstrate that she is fully conversant with the current legislation and the requirements of the Care Home Regulations 2001. To assist with this process, she needs to ensure that Sitara Haven DS0000027715.V286672.R01.S.doc Version 5.1 Page 7 she completes all of the requirements of the Regulations, such as undertaking a review to improve the quality of care and provide a development and financial plan for the current year. The responsibilities of the Registered Provider/Manager and staff to keep the service users free from avoidable risks must be reinforced. An Immediate Requirement was issued in September 2005 regarding the storage of COSHH materials and, on this inspection, the cupboard was once again found to be unlocked. The fire risk assessment still requires a thorough review, taking into account the fact that both permanent service users smoke. 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. Sitara Haven DS0000027715.V286672.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sitara Haven DS0000027715.V286672.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 A more robust system of referral and admission must be in place to ensure that the needs of the service users who are considered for the home fall within the registration category. The facilities, services and staffing must be shown to be able to meet those needs. EVIDENCE: At the last inspection, a new service user had been admitted but limited information had been obtained about his needs. Since the inspection, no further information had been received but a review has been held. The Registered Provider/Manager needs to ensure that any future service users referred are only admitted after a full needs-led assessment has been received and it can be shown that the home has considered these needs and can demonstrate how they will be met. In response to a requirement at the last inspection, the Registered Provider/Manager applied to the Commission for Social Care Inspection for a variation to her registration which was agreed. This was to accommodate the needs of one of the service users who had been in the home for some months. She arranged for training for the staff team in mental health awareness to evidence that the home could meet the needs of the service user. The documentation in the home has not been produced in formats which would specifically suit service users with learning disabilities and it is recommended that this is done to enable them to better understand the contents. Sitara Haven DS0000027715.V286672.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 Service users’ care plans and risk assessments need to be reviewed on a more regular basis and must be seen to be relevant to their current needs. Some progress has been made in encouraging the service users to become more independent. EVIDENCE: The Registered Provider/Manager has care plans in place for the service users but it was found that these have not been fully reviewed. Some care plans were found not be relevant to the support needed and had not been updated following reviews. The Registered Provider/Manager was asked to ensure that the care plans are reviewed at least six monthly, or more frequently when needs change. It needs to be shown that the current care plans are up-todate. She was advised to make sure that they are dated when reviewed and that they are changed to reflect the decisions made at reviews. There is no evidence in the care plan and risk assessment documentation that the service users have been fully involved in the decision making processes. Both of the service users could be more fully engaged in this process and better use could be made of the computer available in the home to involve Sitara Haven DS0000027715.V286672.R01.S.doc Version 5.1 Page 11 them in this. It is recommended that the Registered Provider/Manager actively pursues this. Both service users are able to make their wishes known and service users were seen to be engaged in decision making with the staff. Consultation was seen to take place between the service users and staff on planned activities around the home and in the community. The risk assessments were in need of improvement for all of the service users. These also need to be seen to have been discussed with the service users as restrictions are placed upon them, which include where they smoke in the home, whether or not they are accompanied outside of the house, and whether they have keys to their rooms. These restrictions need to be shown to be agreed with them and their representatives, where applicable, and to have associated risk assessments in place. Those seen, including the fire risk assessment, do not fully examine the possible risks or show how these are minimised. One service user has reverted to more independent travelling since being in the home and it needs to be shown that all of the risks have been considered. Sitara Haven DS0000027715.V286672.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Because the home is small, the service users have the opportunity to go out and about in the community with the Registered Provider/Manager and the staff. EVIDENCE: The home is situated very close to the shops and amenities of Southall Broadway and both service users indicate how much they enjoy activities in the community, such as shopping and going for drives. One service user attends a day centre three days a week and is now travelling by public transport instead of undertaking the journey by taxi. Service users are encouraged to help around the house. The Registered Provider/Manager provides the opportunity for the service users to go on day trips to places such as Windsor. However, a record of activities provided for one service user had not been maintained should be continued to demonstrate the frequency and range of activities provided. There is one day of the week when both permanent service users and two day service clients are in the home but the Registered Provider/Manager said that Sitara Haven DS0000027715.V286672.R01.S.doc Version 5.1 Page 13 trips out of the home are arranged and there are additional staff members on duty, which was confirmed by the duty rota. The service users are also able to accompany the Registered Provider/Manager and other staff members to the local shops and other community activities. One service user particularly enjoys shopping and visits to cafes and the library in Hounslow are regularly taken. The Registered Provider/Manager said that one service user has expressed the wish to go on holiday which will be explored. Both of the permanent service users have families who remain in contact with them and one has weekly visits. Some restrictions have been placed on the service users which need to be documented and be seen to have been discussed with the service users and their representatives. In particular, the permanent service users both smoke and are restricted to doing so in the lounge next to the garden. If non-smoking service users or clients are present, the service users use the garden. The Registered Provider/Manager said that the service users are not allowed to smoke in their bedrooms and that she does not have any concerns with regards to compliance. However, as mentioned elsewhere in this report, this was not shown to have been fully risk assessed, showing how the risks are reduced. A record of meals is kept and the menu showed a variety of English and Asian dishes that both service users enjoy. The staff show a good awareness of the meals that are enjoyed. There is a dining table in one of the lounges for the service users. Sitara Haven DS0000027715.V286672.R01.S.doc Version 5.1 Page 14 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, 20 Although some of the service users’ medical needs have been seen to be met, there is insufficient evidence that there has been the professional involvement required to meet the mental health needs of one of the service users. The Registered Provider/Manager needs to ensure that the appropriate referrals are made and followed up. EVIDENCE: The support that the service users require with their personal care needs is recorded in their care plans. One service user uses the downstairs shower room and toilet, which are located off one of the lounges. The Registered Provider/Manager said that this has not presented any problems with regard to privacy when service users use this facility. The records examined for the two permanent service users showed that most medical and health checks have been undertaken, with visits to the General Practitioner and other health professionals being undertaken. However, the records did not demonstrate that one of the service users has had consistent input from mental health professionals although this appeared to be in the process of being rectified. Where a variation has been granted for a service user, whose needs are outside of the home’s category of registration, the specialist assistance that is required must be seen to be accessed and the Sitara Haven DS0000027715.V286672.R01.S.doc Version 5.1 Page 15 Registered Provider/Manager must demonstrate that every effort is made to maintain it. At the inspection of the home in September 2005, an Immediate Requirement was made regarding the medication storage. The Registered Provider/Manager obtained a small cabinet with a combination lock for storage and this was found to be locked on both this visit and the additional visit made in March 2006. She is now dispensing the medication from the original packaging. When the medication was examined during the additional visit in March 2006, two errors in bringing forward the amount of medication in stock were found. When the stock was checked it was found to correspond with the amount of medication, which should have been dispensed, although the information on the Medication Administration Sheet was incorrect. The Registered Provider/Manager stated that staff members who administer medication are aware of the number of tablets to be dispensed. A requirement was made at that visit regarding the error. At this inspection, there was a discrepancy in the medication, with one tablet too many in stock for one service user. The previous medication administration sheet was not available to verify how this had occurred. The Registered Provider/Manager was unable to explain these discrepancies. She must ensure that the medication handled on behalf of the two service users is regularly checked and that the records are maintained for inspection. Sitara Haven DS0000027715.V286672.R01.S.doc Version 5.1 Page 16 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, 23 The Registered Provider/Manager has made improvements to the complaints procedure to support the service users to use it. The service users’ financial arrangements need to be confirmed as being within with the rules of the financial body with whom the accounts are held. EVIDENCE: In response to a recommendation made at the last inspection, the Registered Provider/Manager has provided the complaints procedure in a visual format which has been made available to the service users and displayed in the hall. No complaints have been recorded relating to the home. At the additional visit made in March 2006, an issue was discussed with the Registered Provider/Manager regarding an alleged incident which took place away from the home and may have involved a member of staff. No further action was taken in regard to this. The Registered Provider/Manager agreed that she would report any notifiable incidents to the Commission for Social Care Inspection, as required under Regulation 37 of the Care Home Regulations 2001. The Registered Provider/Manager had arranged for training in the safeguarding of adults to take place for all of the staff. There have been no reported issues of adult protection in the home. The Registered Provider/Manager was required to improve the record keeping for the service users’ finances and has now done so. However, she said that she holds the Personal Identification Number for one of the service users’ bank accounts. She must ensure that any transactions carried out on behalf of the service users are in accordance with the bank or building society’s rules and make alternative arrangements for withdrawing money if necessary. Sitara Haven DS0000027715.V286672.R01.S.doc Version 5.1 Page 17 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, 25, 27, 28, 29, 30 The home’s environment has not changed since previous inspections. The communal areas continue to be shared with the Registered Provider/Manager’s family and, for part of the week, with two day service clients. The service users have indicated at the last two inspections that they are satisfied with their personal spaces. EVIDENCE: Two communal rooms, both on the ground floor, are available for the use of the two permanent service users. These are shared with the Registered Provider/Manager’s family of four, two day service clients for part of the week, and a service user staying for respite for one weekend a month. It needs to be ensured that the additional services, and the needs of the family, do not encroach on the space available to the service users. It is noted that both tend to use the dining room/lounge, which leads to the garden. This is used as a smoking area if no other non-smoking service users are present. Otherwise the service users are expected to smoke in the garden. It is recommended again that the Registered Provider/Manager discusses this at the service users’ reviews to ensure that there are no concerns about this situation. Sitara Haven DS0000027715.V286672.R01.S.doc Version 5.1 Page 18 If the third bedroom is occupied by a permanent service user, rather than for occasional respite, then the situation will need to be reviewed again to ensure sufficient communal space is available. At the previous two visits to the home, the service users’ bedrooms were seen. The Registered Provider/Manager said that there have been no changes. Both service users have indicated that the rooms suit their needs, although there is a lack of personalisation. It has been the subject of previous recommendations that the service users are supported to make their rooms more individualised and this is repeated. Neither service users has any mobility problems and no specialist equipment is required. The home was found to be clean and hygienic on this visit. Sitara Haven DS0000027715.V286672.R01.S.doc Version 5.1 Page 19 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, 33, 34, 35 Long hours are being worked by two of the staff to be able to provide waking night cover for the permanent service users. This is a possible health and risk and must be kept under review. The access to training has improved. EVIDENCE: Two of the staff have commenced National Vocational Qualification Level 2 and training courses are being held to ensure that all of the staff have the core training required. The home has a small staff team of four, two of whom live in the home. The two remaining staff are generally employed when the respite service user and day service clients are in the home. Because the permanent service users require waking night cover, a system of having one of the two staff who live in the home on duty throughout the night is in place. This means that the shift changes at 3am, with one staff working from 3pm to 10am, and the other from 10am through to 3am the following day. The Registered Provider/Manager said that this system suits the staff but she needs to ensure that the health and safety of the service users and staff is not put at risk by staff working excessive hours. No new staff have been recruited since the last inspection, so no recruitment procedures were examined. Sitara Haven DS0000027715.V286672.R01.S.doc Version 5.1 Page 20 The Registered Provider/Manager has commenced one-to-one supervision sessions with the staff team, which are recorded. The last staff meeting seen to have taken place was in November 2005 and it is recommended that these are held more regularly to support the staff and to discuss the needs of the service users and how they are supported. Sitara Haven DS0000027715.V286672.R01.S.doc Version 5.1 Page 21 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, 38, 39, 40, 41, 42, 43 While some improvements have been made to the running of the home, the Registered Provider/Manager still needs to demonstrate that the Care Home Regulations 2001 are being fully met and any improvements that are made to comply with these are maintained. EVIDENCE: The Registered Provider/Manager has, at previous inspections, not shown that she is fully conversant with Care Home Regulations 2001 and National Minimum Standards. This has been evident from the number of requirements that have been made in the past, some of which have been repeated on several occasions. Although the Registered Provider/Manager has made some progress in complying with the requirements made from the last inspection, a further thirteen have been made at this inspection. Where improvements are made to the record keeping and general running of the home, she must ensure that these are maintained. Both of the service users were seen to have a good relationship with the Registered Provider/Manager and the staff member of duty. Sitara Haven DS0000027715.V286672.R01.S.doc Version 5.1 Page 22 No review of the quality of care, in accordance with Regulation 24 of the Care Home Regulations 2001, has been carried out. The Registered Provider/Manager must ensure that, on a regular basis, she looks at how the quality of care in the home can improve. This needs to take into account the views of the service users and their representatives. Although there are only two permanent service users in the home, it was found on the last two visits to the home that more attention is still required to be paid to keeping records up-to-date and accurate. This included the care planning, risk assessments and medication administration records. The Registered Provider/Manager was required to ask the London Fire Brigade to look at the fire precautions in the home as there are now two service users who smoke. A visit took place from the London Fire Brigade on 23rd March 2006. The Registered Provider/Manager said that the officer found the home satisfactory. No documentary evidence was available. COSHH materials are stored in the small office of the home in a lockable drawer. On this inspection, the drawer was found to be unlocked. At the last inspection, in September 2005, an Immediate Requirement was issued for the same reason. These materials are potentially hazardous and the Registered Provider/Manager must ensure that service users are not put at risk by staff not being vigilant about keeping the materials locked away, particularly as the office is not locked. The fire extinguisher check and the Landlord’s Gas Check were last carried out in September 2005. Regular fire drills appeared to be held but the documentation was not clearly recorded. The Registered Provider/Manager produced a development plan up until June 2005 which included the plans for training and the environment. An up-todate plan must be produced for the current year to show the financial viability of the home. Sitara Haven DS0000027715.V286672.R01.S.doc Version 5.1 Page 23 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 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 2 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 1 x 2 3 2 X 2 2 2 Sitara Haven DS0000027715.V286672.R01.S.doc Version 5.1 Page 24 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 YA3 Regulation 14 & 15 Requirement Timescale for action 30/05/06 2 YA6 15 (2) (b) 3 YA9 13 (4) (b) (c) 4 YA19 12 (1) (a) (b) 5 YA20 13 (2) The referral and assessment procedures must be followed in the event of any new service user being considered for a placement in the home. Care plans must be seen to be up- 30/06/06 to-date, and reviewed on a regular basis, in consultation with the service users and their representatives. All of the risk assessments must 30/06/06 be updated and be shown to consider all of the risks identified for each service user and demonstrate how these are minimised. Where a variation has been 30/06/06 granted for a service user whose needs are outside of the home’s category of registration, the specialist assistance that is required must be seen to be accessed. The Registered Provider/Manager 30/04/06 must ensure that that the service users’ medication stock is regularly checked to ensure it is administered correctly and the records of administration must be maintained for inspection. DS0000027715.V286672.R01.S.doc Version 5.1 Page 25 Sitara Haven 6 YA23 13 (6) 7 YA28 23 (2)(g) (h) 8 YA33 13 (4) (c) 18 (1) (a) 9 YA37 9 (2) (b) (i) 10 YA39 24 (1) (2) 11 YA41 17 12 YA42 23 (4) (v) The Registered Provider/Manager must ensure that service users are only supported with financial transactions in accordance with the rules of the financial body where the account is held. The use of the facilities must be seen to be kept under review, on a regular basis, in consultation with the service users, to ensure that there is sufficient communal space available for the permanent and respite service users. The staffing levels must be kept under review to ensure that sufficient staff are employed to cover the rota to ensure that the health and safety of the staff and service users is not compromised. The Registered Provider/Manager must to ensure that she is fully conversant with the current legislation and the requirements of the Care Home Regulations 2001, maintaining records and documentation in line with Schedules of the Care Home Regulations 2001. The Registered Provider/Manager must undertake a review to improve the quality of care, on a regular basis, and in consultation with the service users and their representatives. Copies of the report must be provided to the service users and the Commission for Social Care Inspection. The record keeping must be maintained in good order, in accordance with Schedules 3 and 4 of the Care Home Regulations 2001, kept up-to-date and reviewed as required. The fire risk assessment must be completed to take into account the potential hazards of the service users smoking and how they can be met by the fire precautions. DS0000027715.V286672.R01.S.doc 31/05/06 30/06/06 30/06/06 31/05/06 31/07/06 30/06/06 30/06/06 Sitara Haven Version 5.1 Page 26 13 14 YA42 YA43 13 (4) (a) & (c) 25 (1) (Previous timescales and 31/5/05 and 31/10/05 not fully met) The COSHH materials must be stored securely at all times. The Registered Provider/Manager must provide a financial and development plan to demonstrate the viability of the home. 30/04/06 30/06/06 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 YA1 YA8 Good Practice Recommendations That the documentation available for the service users should be produced in formats which would specifically suit service users with learning disabilities. That the computer available in the home is used to engage the service users in the production of their care plans and risk assessment and enables them to participate fully in this process. That the Registered Provider/Manager discusses the situation regarding the communal space available at the service users’ reviews to ensure that there are no concerns about this situation. That service users are supported to personalise and improve their individual living spaces. That more regular staff meetings are held to support the staff and to discuss the needs of the service users and how they are supported. 3 YA24 4 5 YA25 YA36 Sitara Haven DS0000027715.V286672.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST 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 Sitara Haven DS0000027715.V286672.R01.S.doc Version 5.1 Page 28 - 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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