Inspection on 12/04/05 for Sitara Haven

This inspection was carried out on 12th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. 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 10/04/06

Sitara Haven 30/09/05

Sitara Haven 26/08/04

Sitara Haven 13/04/04

Sitara Haven 18/12/03

Sitara Haven 03/07/03

Similar services:

Ashlong House

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Edenvale

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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 Jane Collisson Unannounced 12 April 2005 at 9.30am 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 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 Stationary 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 Version 1.10 Page 3 SERVICE INFORMATION Name of service Sitara Haven Address 23 Hambrough Road, Southall, Middlesex UB1 1HZ Telephone number Fax number Email 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 867 9590 0208 893 5342 Mrs Rajinder Hunjan Mrs Rajinder Hunjan Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Sitara Haven Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 28/8/04 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 overlooks the garden and has a dining table. 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 is the Registered Provider/Manager and two male 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 Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 12th April 2005 from 9.30pm to 4.15pm for a total of six hours. The Registered Manager/Provider was present. The home currently has one service user, who has moved in since the last inspection of the home in August 2004. The home is also providing a day service to two people, on two days of the week. There were no respite service users. It was found that the Registered Manager/Provider has admitted a service user whose needs are not fully within the category that the home is registered to provide. She is in discussion with the Commission for Social Care Inspection regarding this and will need to demonstrate that the service user’s needs can be met if he is to remain in the home. The Registered Manager/Provider had completed seventeen of the twenty two requirements made at the inspection in August 2004. The remainder are repeated in this report and a further eight requirements have been made, including two Immediate Requirements issued because of errors in the medication administration and the high temperature of the hot water in the bath and shower. As there is only one service user in the home, the current staff team is confined to the Registered Manager/Provider and one other staff member. The third staff member only works in the home when the day service clients are present on two days of the week. During this inspection, the service user was being supported to attend a health appointment, to visit a supermarket and to have a meal out. The service user confirmed that he was able to choose to stay in his bedroom or to use the communal facilities in the house. Access to satellite television is available to enable service users to watch Asian programmes and, as the home is located in central Southall, there are cultural and religious facilities close by. A variety of meals were seen to be offered and recorded. The service user confirmed that the meals are of his choice, that Asian or English food can be provided, and that eating out is an option which is enjoyed. No visitors were seen on the day of the inspection but it was confirmed by records and by the staff and service user that regular visits are made, to the home, by the service user’s family. No further staff training had taken place since the last inspection, although a service user with specialist needs has been admitted. Sitara Haven Version 1.10 Page 6 Because the home has only one service user, the facilities and services which would be available if the home was occupied by three permanent service users could not be evaluated fully. What the service does well: What has improved since the last inspection? What they could do better: The Registered Manager/Provider needs to ensure that the requirements made by the Commission for Social Care Inspection are acted upon as these have an impact on the services which are provided in the home. In particular, the Registered Manager/Provider must ensure that her systems for monitoring medication are robust. The current staff team have only undertaken basic mental health training and need to have further training to demonstrate that the needs of the service user who has been admitted can be understood and met. The Registered Manager/Provider has not provided sufficient information to show that all of the risk assessments required have been considered in respect of the service users accommodated in the home, both permanently and day services. Health and safety checks must form part of the Registered Manager/Provider’s monitoring systems to ensure that items, such as the hot water temperatures, are tested on a regular basis. The hot water regulator on the bath was no longer working. The bath tap and the shower was delivering water at over 50 degrees centigrade. This was the subject of an Immediate Requirement. A further Immediate Requirement was made in respect of medication stock keeping where errors were found. Further requirements were made in respect of improvements to the care planning, risk assessments and documentation in the home. Sitara Haven Version 1.10 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Sitara Haven Version 1.10 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 Standards Statutory Requirements Identified During the Inspection Sitara Haven Version 1.10 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 standard(s) 1, 2, 4, 5 The information provided for service users and their representatives needs to clarify the service that the home can offer in relation to the facilities and staffing available. It is not demonstrated that the needs of the current service user can be fully met by the home as there is a lack of specialist training and understanding of his needs. EVIDENCE: The information that new service users would require to enable them to make a decision about living in the home has not all been completed. The Statement of Purpose and Service Users Guide have been amended since the last inspection but need to show better how the needs of the service users can be met by the home. The home’s additional services, respite and day services, need to be included in the Statement of Purpose and to show how these may impact on the lives of permanent service users who may choose to live in the home. The Statement of Purpose needs to inform prospective service users that the Registered Manager/Provider’s family also live on the premises and clarify how the accommodation is shared with them and the day service clients. In order for the current service user, and new service users, to understand better the facilities available in the home, consideration should be given to producing the Service Users Guide in user-friendly formats or other languages. Sitara Haven Version 1.10 Page 10 The current service user has been admitted since the last inspection, following an assessment by the Registered Manager/Provider. Although care plans have been produced, those examined did not fully identify all of the needs of the service user and need to be expanded to do so. The Registered Provider does not have a category of registration to meet one of the needs of the service user and the Statement of Purpose only specifies that the home can meet the needs of people with learning disabilities. She is required to demonstrate that the service user’s needs have been fully identified and that she and her staff team can meet them. The Registered Manager/Provider did not confirm in writing that the service user’s needs could be met by the home, prior to admission. This is required by Regulation 14 (1) (d) of the Care Homes Regulations 2001. In view of the concern of taking a service user out of the home’s category of registration, this would have provided the opportunity to demonstrate to the purchasers as to whether the service user’s requirements could be accommodated. The opportunity has been given to the recently admitted service user to have a three month trial period to decide if the home is suitable. No decision had been made regarding permanency and the Registered Manager/Provider was not able to say when this was to be considered. The service user has been issued with the contract/terms and conditions and the Registered Manager/Provider provided a copy of the purchaser’s contract to the service user during this inspection. This fulfils two requirements made at the previous inspection and gives the opportunity for the service user or his representatives to understand the rights and responsibility of the placement. Sitara Haven Version 1.10 Page 11 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 standard(s) 6, 7, 8, 9 Some limited progress has been made in the care planning process. Whilst there is evidence that the current service user has choice about the daily living tasks and activities, the areas of risk have not been shown to have been considered fully. EVIDENCE: Care plans are in place for the service user currently in the home but are not adequate to identify all of the needs described in the assessment from the purchaser. This includes all of the risk assessments required for protection. The plan has information on the restrictions placed on the service user, such as going out alone, and the service user was able to confirm that these are acceptable. The service user confirmed that he is able to make decisions regarding meals and outings and other aspects of daily life and was able to give examples of activities he enjoys. A daily programme has been compiled of the activities planned for each week. The Registered Manager/Provider said that the service user is offered the opportunity to participate in the day-to-day running of the home, and the Sitara Haven Version 1.10 Page 12 activities are recorded in the service user’s care plan. These included helping in the kitchen and the preparation of simple meals. In order to safeguard the health and safety of the service users in the home, it was required that risk assessments must be in place for all activities, including the call system and bathing, when new service users are admitted. These were not in place for the current service user and the Registered Manager/Provider was informed that she must ensure that all of the risks likely to be taken by the service users must be identified and the risks minimised. Because the hot water temperature in the shower room and bathroom were over 50 degrees centigrade the service user was potentially at risk. An Immediate Requirement was issued to regulate the hot water to a safe temperature (see Standard 42). Sitara Haven Version 1.10 Page 13 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 standard(s) 12, 13, 14, 15, 16 and 17 The service user’s care plan indicated the activities which he enjoys, which he was able to confirm. Because the service user had been in the home for only a short period, the activities mainly consist of shopping and meals out and further opportunities will need to be provided for personal development. EVIDENCE: The service user confirmed that he prefers not to take part in organised activities, such as day centres or drop-in facilities. The staff at the home provide outings on a regular basis to local shops and facilities such as the library. The home is located in a residential area of Southall, very close to the shops and facilities of Southall Broadway. This enables the service user to be supported to visit a place of worship if he wishes to do so and the Registered Manager/Provider confirmed that he had chosen to do so occasionally. The service user is able to see family members on a regular basis who visit the home. There are two lounges, so private meetings can be facilitated. Sitara Haven Version 1.10 Page 14 The service user’s care plan indicated that he did not have a key to the home or his bedroom. This was detailed in the care plan but the reasons for this were not fully clarified. He said that he did not have a key to the locked space to the locked space in his bedroom and this should be provided. The service user was seen to be able to choose where he wished to be in the home, such as the bedroom or a communal area. The service user confirmed that there is choice of meals and they meet chosen preferences although a mealtime was not observed on this inspection as the service user had a meal out with a member of staff. The Registered Manager/Provider said that the menu had been drawn up in consultation with the service user and includes the provision of Asian and English meals. A record is made of the meals taken at breakfast, lunch and in the evening and a varied diet was seen to be provided. The Registered Manager/Provider confirmed that the service user is encouraged to assist and can cook simple meals under supervision. There is space in the larger lounge for the service users to have meals. Sitara Haven Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19 and 20 The personal care and physical health needs of the service user were seen to be met by the home. However, the Registered Manager/Provider has not had sufficient training, or previous experience, to meet the mental health needs of the service user and could not demonstrate that these have been fully considered. The medication administration is unsatisfactory as errors in stock control were found. EVIDENCE: A plan of personal care was available and the Registered Manager/Provider confirmed that although there is minimal assistance required, the service user does require support and guidance. The service user is aware that there is the choice of a bath or a shower. The records evidenced that the service user has been registered with a General Practitioner and has visited other health professionals as required. Information regarding future appointments was seen. The service user was being supported by staff to attend these. The service user does not self-medicate and medication held for the service user was examined. The Registered Manager/Provider had a requirement at the previous inspection in August 2004 to keep records of the medication brought into the home. A system was in place to record the medication received. However, a check of the medication in stock against the Medication Sitara Haven Version 1.10 Page 16 Administration Record sheets, since the service users had been in the home, showed inaccuracies in the amount of medication which should have been in stock. Medication was signed for on days marked the 29th and 30th February which was not possible. This, however, did not account fully for the discrepancies. An Immediate Requirement notice was issued to the Registered Manager/Provider to check the medication stock on the day of the inspection and put into place a system to monitor the medication . Sitara Haven Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 The complaints procedure will need to be provided in a suitable format for the service user. The Registered Manager/Provider did not have guidance in place regarding the protection of the service user and others. EVIDENCE: There is a complaints procedure in place although it was not demonstrated that the service user was aware of how this could be used. It is recommended that the Registered Manager/Provider enables the service user to understand the complaints procedure by providing the information in other formats or languages which may be more appropriate. Since the last inspection in August 2004, an adult abuse allegation has been the subject of an investigation by the London Borough of Ealing and a member of staff was suspended. The service user concerned no longer has a service at the home and no evidence was found to substantiate the complaint. There was insufficient information in the home regarding how the service users who use the home, either on a permanent basis or for the day service, are dealt with should there be aggressive behaviour. The Registered Manager/Provider was asked to ensure that guidance and risk assessments are in place to protect the rights and best interests of the service users. Where required, guidelines must be in place to protect other service users, staff and other people in or outside the home. The service user’s finances are dealt with by his family and the Registered Manager/Provider holds only a small amount of money on behalf of the service user. Sitara Haven Version 1.10 Page 18 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 standard(s) 24, 25, 27, 28, 30 The home is maintained in a reasonable condition, although there are areas of the kitchen which need to be maintained with regard to cleanliness. The lack of natural light and ventilation in one of the lounges is not desirable but another, more spacious and ventilated lounge, is available. Although the service user confirmed that the bedroom suits his needs, a more comfortable and personalised space could be achieved with encouragement. EVIDENCE: Because the home has not been fully occupied on the recent inspection visits to the home, it cannot be ascertained if there is sufficient and suitable space should the home be occupied by three permanent service users, the Registered Manager/Provider’s family of four and any day service clients that were receiving a service. The service users have the use of two lounges, two bathrooms, a kitchen and garden. One lounge has no natural light and the other is used as the dining room and also by service users who smoke. The Registered Manager/Provider needs to keep this under review if the remaining places are filled. The service user was seen privately and confirmed the facilities he has suites his needs. There are currently no personal items and the service user should Sitara Haven Version 1.10 Page 19 be encouraged to personalise the room if he wishes to do so. There are television and music facilities in the bedroom for the service user’s personal use. There are two bathrooms which are shared by the service users, day service clients and the Registered Manager/Provider’s family. One has a shower and toilet, located on the ground floor, and one a bath and toilet. All service users have single bedrooms which can offer privacy and space to entertain visitors. One of the lounges is used by any service users who smoke, although the Registered Manager/Provider said that service users who smoke may not do so in the lounge if other, non-smoking, service users are present and object. With only one service user in the home, this was not an issue. The home was found to be in a reasonably clean and hygienic condition although areas of the kitchen, such as the tiling, would benefit from deep cleaning. The washing machine and dryer have been moved from the kitchen to the office to improve infection control, as required at the previous inspection. Sitara Haven Version 1.10 Page 20 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35 It was not demonstrated that the staff have sufficient expertise and training to meet the needs of a service users with mental health needs and this has to be addressed. EVIDENCE: The home currently employs two staff in addition to the Registered Manager/Provider. One is employed part-time to work with the day service clients. The hours for each of the services, permanent and day services, have been separated as required at the previous inspection. This was requested to demonstrate the home’s permanent service users have access to sufficient staff hours to meet the service users’ needs. The rota showed that the staff work from 10am to 1am to provide a service to the current service user. These hours would need to be adjusted should needs change or new service users be admitted. It was shown that the staff team of three had undertaken the basic training courses at the last inspection. The Registered Manager/Provider confirmed that no further training had taken place since then. Staff have had only an introduction to mental health one-day course. This is insufficient to meet the needs of the service user admitted and further, appropriate training must take place to demonstrate that the staff have the understanding to support a service user with mental health needs. Sitara Haven Version 1.10 Page 21 No new staff have been appointed since the last inspection so the recruitment practices could not be assessed. Sitara Haven Version 1.10 Page 22 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39, 42 Because insufficient monitoring has taken place with regard to hot water temperature testing and medication, Immediate Requirements had to be issued and this is an area where improvements are required. EVIDENCE: Because of the small number of service users in the home in the last year, a review of the quality of care has not been undertaken. However, the Registered Manager/Provider requested the service user to complete a questionnaire during the inspection which was satisfactory. A review of the quality of care will be required to be held in due course. When the hot water was tested in the bath and shower, it was found to be delivered at over 50 degrees centigrade which would be potentially dangerous for service users. One water regulator was found to be broken. An Immediate Requirement was issued to the Registered Manager/Provider to have the hot water regulated to a safe temperature of around 43 degrees centigrade. The Registered Manager/Provider confirmed that this work has been carried out. Sitara Haven Version 1.10 Page 23 A door holding system being used in the interior lounge, which activates when the fire alarm is sounded, was found to be on a timer and would not remain open until after 10am. It was suggested to the Registered Manager/Provider that this is adjusted so that the door to the room can be kept open at other times. There were health and safety requirements outstanding from the previous inspection which had not been actioned. These were that the Registered Manager/Provider must enquire from the London Fire and Emergency Planning Authority that the required signage for fire precautions is in place, and that the fire risk assessment must be completed to take into account the needs of the service user group and how they can be met by the fire precautions. These have both been repeated. Sitara Haven Version 1.10 Page 24 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 1 x 3 3 Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 3 3 1 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x 3 3 x 3 Standard No 11 12 13 14 15 Sitara Haven x 3 3 3 3 Standard No 31 32 33 34 35 36 Score x 2 x x 1 x Version 1.10 Page 25 16 17 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 1 x Sitara Haven Version 1.10 Page 26 YES 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 YA1 Regulation 4 (1) (c) Requirement The Statement of Purpose must be in accordance with Standard 1 and Regulation 4 (1) (c). It must be produced in formats suitable for the service users. (Previous timescale of 31/10/04 not fully met) The Registered Manager/Provider must detail in the Statement of Purpose how the services provided in the home are accommodated. (Previous timescale of 31/10/04 not met) The needs of new service users must be assessed in sufficient details to identify that all of their needs can be met by the home. Service users must not be admitted outside of the category the home can accommodate. It must be confirmed to new service users in writing that the home can meet their needs. The care plans for the service user must identify all of their assessed needs and provide information on how they will be met. The Provider/Manager must ensure that risk assessments are properly assessed and risks are Version 1.10 Timescale for action 31/5/05 2. YA1 4 (1) (b) 30/6/05 3. YA2 14 (1) (a) (c) 31/5/05 4. 5. YA2 YA6 14 (1) (d) 15 (1) & (2) 31/5/05 31/5/05 6. YA9 13 (4) (c) 31/5/05 Sitara Haven Page 27 7. YA16 12 (3) 12 (4) (a) 8. YA20 13 (2) 9. YA23 13 (4) (b) & (c) 10. YA32 and YA35 18 (1) (a) 11. YA42 13 (4) 12. YA42 23 (4) (c) (iii) 13. YA42 23 (4) (v) minimised. (Previous timescale of 31/10/04 not met) Reasons for the the restrictions placed on service users, such as not having keys to bedrooms or locked spaces, must be recorded. The medication held must be monitored regularly to ensure that the correct stock is maintained. (IMMEDIATE REQUIREMENT ISSUED). Guidance and risk assessments must be in place to minimise the risks of aggressive behaviour to service users, staff and visitors to the home. The Registered Manager/Provider and the staff team must undertake all of the specialist training required to meet the needs of the service users admitted to the home. The hot water temperature in the bath and shower must be regulated to be delivered at around 43 degrees centigrade. (IMMEDIATE REQUIREMENT ISSUED) The Registered Manager/Provider must enquire from the London Fire and Emergency Planning Authority that the required signage is in place.(Previous timescale of 31/10/04 not met) The fire risk assessment must be completed to take into account the needs of the client group and how they can be met by the fire precautions. (Previous timescale of 31/10/04 not met) 31/5/05 12/4/05 31/5/05 30/6/05 26/4/05 31/7/05 31/5/05 Sitara Haven Version 1.10 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA 22 Good Practice Recommendations It is recommended that the Registered Manager/Provider enables the service user to understand the complaints procedure by providing the information in other formats or languages which may be more appropriate. Sitara Haven Version 1.10 Page 29 Commission for Social Care Inspection Ground Floor 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. 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