Inspection on 12/09/06 for Sitara Haven

This inspection was carried out on 12th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 7 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 10/04/06

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

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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 Ms Jane Collisson Key Unannounced Inspection 12th September 2006 12:20 Sitara Haven DS0000027715.V310656.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 Sitara Haven DS0000027715.V310656.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. Sitara Haven DS0000027715.V310656.R01.S.doc Version 5.2 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.V310656.R01.S.doc Version 5.2 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. 10th April 2006 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. There is, however, a variation to the conditions of registration to accommodate a service user with mental health difficulties. The home is owned and managed by Mrs. Rajinder Hunjan and 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 a shower room and toilet on the ground floor, and a bathroom with a toilet on the first floor. The communal facilities are shared with the owner’s family. One lounge, which is also the 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 provides respite care at weekends when the permanent places are not filled. There are also day services provided for up to three clients, for up to four days a week, sharing the same communal facilities with the permanent service users. The current fees in the home range from £550 to £888 per week. Sitara Haven DS0000027715.V310656.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 12th September 2006 from 12.20pm. The inspection process took a total of three hours. The Registered Provider/Manager was present throughout the inspection, together with two staff members. Both of the permanent service users were in the home and were seen in private. One permanent vacancy remains and a respite service user currently uses the room one weekend a month. A day service client was also present during this inspection. Three day service clients use the service on four days of the week, with a maximum of two clients in the home on any day. This has been an increase since the last inspection and this situation must be kept under review to ensure that the home provides sufficient space, staffing and activities for the permanent service users. There have been no changes since the last unannounced inspection to the staff team of four. One staff member is employed to work mainly with the day service clients. All of the service users and clients using the home at present are male. Both of the permanent service users expressed their satisfaction with the services provided in the home. For a full assessment of all of the key standards, this report should be read in conjunction with the inspection report of the 10th April 2006. At that inspection, fourteen requirements were made of which eleven have now been met. Three were not fully met and have been repeated. An additional four have been made. What the service does well: What has improved since the last inspection? What they could do better: Because of the number of service users and family members living in the home, together with an increased number of day service clients, the Registered Provider/Manager needs to ensure that this information is available to all current and prospective service users, through the Statement of Purpose. Sitara Haven DS0000027715.V310656.R01.S.doc Version 5.2 Page 6 She needs to demonstrate that there are sufficient facilities, services and staff numbers available in the home to ensure that the needs of the permanent service users continue to be met and there is no impact on their support from the increase in day services. Although some work has been undertaken on gaining views about the quality of care, there has been no report to show how the care will be developed and improved. Whilst there have been improvements in the health and safety in the home, the Legionella testing was overdue. The Registered Provider/Manager needs to ensure that all health and safety checks are undertaken as required. 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.V310656.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 Sitara Haven DS0000027715.V310656.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Because no new service users have been admitted or referred to the home since the last inspection, the key standard could not be assessed. Information is in place to inform prospective service users of the home’s facilities and services. However, its production in more user-friendly formats would support the service users to better understand the information. Additional day services have been provided in the home and the Statement of Purpose needs to reflect the impact of this on the permanent service users. EVIDENCE: No changes have been made to the Statement of Purpose since the last inspection, although the amount of day services provided in the home has increased. The Registered Provider/Manager needs to ensure that any prospective service users, and the current service users and their representatives, are fully aware of this and the impact on the facilities and services available in the home for their use. In order to provide information which would assist the service users to better understand the information in the Service Users Guide, it was recommended at the last inspection that it is produced in visual formats. The Registered Provider/Manager said that this has not been produced but she is still looking into providing this. Sitara Haven DS0000027715.V310656.R01.S.doc Version 5.2 Page 9 As no new service users have been referred or admitted to the home, the key Standard in the section could not be fully assessed. However, the Registered Provider/Manager has produced some guidance on the process of admission to ensure that procedures are followed. Although the service users have been issued with terms and conditions, the Registered Provider/Manager said that the fees have not been updated on the documentation and she was advised that this should be completed to ensure that service users and their families are fully aware of the current fees and costs in the home. Sitara Haven DS0000027715.V310656.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Work has been carried out to assessments and make them extended to include all of the able to make decisions about EVIDENCE: Care plans are in place for the permanent service users and these have been updated and produced in a clearer format, using the computer. This was a requirement at the last inspection. However, the care plan for the respite service user had not been updated and this needs to be carried out. Both of the service users confirmed that they are able to made decisions about their daily lives and were seen to do so during the inspection. Risk assessments had been updated as required. The restrictions placed upon one service user, in regard to going out unaccompanied, have been agreed with the service user and his representatives. Both service users smoke and Sitara Haven DS0000027715.V310656.R01.S.doc Version 5.2 Page 11 improve and update the care plans and risk more accessible. However, this must be service users in the home. Service users are their daily living activities. there are limited areas where this take place. The Registered Provider/Manager said that the service users are aware of the restrictions and are willing to comply with them. Sitara Haven DS0000027715.V310656.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users have had opportunities for personal development, including improved travel skills, and to undertake the leisure activities they enjoy. EVIDENCE: The service users confirmed that they have the opportunity to undertake the activities they prefer, which include shopping and outings with the Registered Provider/Manager and staff. The shopping centre of Southall is within a very short walk and the service users also enjoy going to Hounslow and other local areas. One of the lounges has been improved with the addition a large table for the service users and day service clients to use for activities and one service user was engaged in improving his writing skills. Family relationships are maintained and both permanent service users have relatives who visit regularly and with whom they go out. One recently attended a cultural festival with a relative. The service users have been given Sitara Haven DS0000027715.V310656.R01.S.doc Version 5.2 Page 13 the opportunity to visit their respective religious establishments but have declined to do so. One service user attends a day service three times a week, which he indicated he enjoys. Since being accommodated in the home, he has improved his independent travel skills and is able to use public transport alone to go to and from the centre. Both service users have participated in a holiday to Jersey this year with the Registered Provider/Manager and her family. The menu seen reflected a variety of meals which include English and Asian foods. The Registered Provider/Manager showed an awareness of the likes and dislikes of the service users and is able to meet a variety of preferences. The service users confirmed that they enjoy the meals. Sitara Haven DS0000027715.V310656.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are being supported by the staff to access both the community health facilities and professionals for their specialist medical needs. The medication procedures were in better order than at previous inspections. EVIDENCE: Personal support is provided in line with each service user’s individual needs. The Registered Provider/Manager said that both service users require some prompting with personal care. Evidence was seen in the files that the health needs of the service users are being monitored and that they are encouraged to try and improve their general health. One service user has been diagnosed with diabetes since the last inspection and the Registered Provider/Manager was in the process of trying to arrange a further appointment with the diabetic nurse, who monitors the blood sugar levels. She said that she had checked with the medical staff that the menu being provided is suitable for a service user with diabetes. Both service users smoke and the Registered Provider/Manager said that the service users are being supported to try and follow a more healthy lifestyle. Sitara Haven DS0000027715.V310656.R01.S.doc Version 5.2 Page 15 The specialist mental health assistance required for one of the service users had been proving difficult to access at the last inspection. The Registered Provider/Manager was required to ensure that, where a variation has been granted for a service user with specialist health needs to be admitted to the home, she must endeavour to ensure that the appropriate support is obtained. She explained the difficulty in accessing some specialist Community Psychiatric Nurse services, which are only available in the event of a crisis. A behavioural therapist had visited on a number of occasions and was working with one of the service users currently. It was a requirement at the last inspection that the medication stock control was improved. The medication records checked on this inspection were found to be satisfactory. The Registered Provider/Manager obtains the medication on a weekly basis from the chemist, and uses handwritten medication administration sheets, as she finds this the most effective way of ensuring good stock control. Only the two staff living in the home administer medication but the Registered Provider/Manager said that training is to be given again shortly to all staff. Sitara Haven DS0000027715.V310656.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. While service users indicated that they were happy with the services provided, it is recommended that further work is seen to be carried out with the service users to ensure that they feel able to express any concerns. EVIDENCE: No complaints have been recorded in the home. Although the service users showed some awareness of how they would voice their concerns, further work could be carried out with them, by the Registered Provider/Manager and staff, to support them to do so. It is recommended that further work is carried with the service users regarding raising their concerns or complaints. There have been no adult protection issues in the home since the last inspection. The staff are undertaking a training course, using a work book, on adult protection. Some changes have been made to the financial arrangements for one of the service users whose benefits, after a long period, have now been put into order and a bank account opened. The Registered Provider/Manager said that he is supported with his financial arrangements by the staff and records are maintained, which were seen. The other service user has his finances managed by the mental health team. Sitara Haven DS0000027715.V310656.R01.S.doc Version 5.2 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, 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Because the home accommodates day service clients and the Registered Provider/Manager’s family, the space available on some days is limited. This situation must be monitored on a regular basis to ensure that the permanent service users have sufficient space, privacy and staff available to meet their needs. The home is being maintained in a reasonable condition. EVIDENCE: There have been no major changes to the home’s environment. The Registered Provider/Manager said that the vacant bedroom had been decorated and she intends to decorate the kitchen and larger lounge next year. This lounge is also used as a dining room and the large dining table provides the service users with the opportunity for activities such as painting and games. This room is also used by the day service clients. There is a second, internal lounge and all of the communal areas are also shared with the Registered Provider/Manager and her family. Because of the limited space in the home, the Registered Provider/Manager had been recommended to ascertain at reviews whether service users and their representatives have Sitara Haven DS0000027715.V310656.R01.S.doc Version 5.2 Page 18 concerns about this. She said that this has been discussed and no problems have been raised. The service users did not express any concerns during this inspection. However, there has been an increase in the number of day service clients. Although the impact is lessened by the current vacancy, should a third permanent service user be admitted, the Registered Provider/Manager must review the situation. She must also monitor the current situation with regard to privacy, staffing and the space available by providing details of the number of service users and clients in the home each day and the staffing available during that time. There are two bathrooms and toilets, one with a bath and one with a shower. The Registered Provider/Manager said that the current service users prefer to use the ground floor shower room, which is located off one of the lounges. No special equipment is required for the service users, who are both fully mobile. The areas of the home seen on this inspection were seen to be clean and tidy. The service users showed the Inspector their bedrooms, which were both found to be maintained in good order. There is a limited amount of personalisation in the bedrooms but both service users indicated that the rooms suited their needs. Sitara Haven DS0000027715.V310656.R01.S.doc Version 5.2 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, 34, 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Training has been provided to all of the staff team and is ongoing. The staffing levels appear satisfactory at present but need to be kept under regular review as they also provide cover for the day service, which has increased. EVIDENCE: There have been no changes to the staff team, which consists of the Registered Provider/Manager, and three care staff, since the last inspection. Because waking night cover is provided, and two of the staff live on the premises, the main shifts undertaken by them are from 3pm to 3am and 3am to 10am, with other staff covering the hours between 10am and 6pm. The day service has increased and the number of staff remain the same. The Registered Provider/Manager must keep this under review and demonstrate that sufficient staffing is provided when all of the service users and day service clients are in the home. Information is required to be provided on the number of staff and hours of work for the services provided to permanent service users, respite service users and day service clients. No new staff have been recruited since the last inspection, so the recruitment procedures were not assessed. Sitara Haven DS0000027715.V310656.R01.S.doc Version 5.2 Page 20 A number of training courses are being undertaken with the use of work books which are verified by the training company. These include training on adult protection and fire. The Registered Provider/Manager said that training on diabetes, epilepsy and medication have been arranged from October. Two of the staff are undertaking their National Vocational Qualifications Level 2. Sitara Haven DS0000027715.V310656.R01.S.doc Version 5.2 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, 39, 42, 43 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Consistency has been provided for the permanent service users as there have been no changes to the staff team. Limited work has been carried out on quality assurance with regard to an improvement plan for the home. EVIDENCE: The management and staffing of the home have not changed so some consistency and stability is provided for the service users. A good rapport was noted between staff and service users. The Registered Provider/Manager had been required to ensure that a review of the quality of care was provided, in accordance with Regulation 39 of the Care Home Regulations 2001. This was a long outstanding requirement, which has now been partially fulfilled. The Registered Provider/Manager undertook a survey of representatives and professionals but has not produced an improvement plan. She needs to show how the home will develop and improve Sitara Haven DS0000027715.V310656.R01.S.doc Version 5.2 Page 22 for the benefit of the service users. Some improvements to the record keeping were noted, as required at the previous inspection, and the Registered Provider/Manager has fulfilled most of the requirements made at the last inspection. There were no health and safety issues identified at this unannounced inspection. The COSHH materials, which had been found to be kept in an unlocked cabinet at previous inspections, and were the subject of a requirement at the last inspection, were being kept securely. The fire drills are being carried out monthly and all of the staff have taken part recently. The fire alarm system is tested weekly. Small electrical testing was carried out on the 1st September 2006 but the Legionella testing was overdue. The Registered Provider/Manager undertook to have this completed. The Registered Provider/Manager had been asked to provide a financial and development plan to demonstrate the viability of the home which she was able to produce at this inspection. Sitara Haven DS0000027715.V310656.R01.S.doc Version 5.2 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 3 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 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 2 X 3 2 3 Sitara Haven DS0000027715.V310656.R01.S.doc Version 5.2 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 YA1 Regulation 4 (1) (b) Timescale for action The Registered Provider/Manager 31/10/06 must ensure that the Statement of Purpose reflects the impact on the facilities and services provided in the home due to the increase in day service provision. This must be available to prospective service users, and the current service users and their representatives. Service users must be provided 31/10/06 with up-to-date information on the fees and services. All of the service users in the 31/10/06 home must have an up-to-date care plan. (Previous timescale of 30/06/06 not fully met) To demonstrate that there is the 31/10/06 sufficient space and privacy to meet the needs of the permanent service users, the Registered Provider/Manager must provide information on the number of service users and day service clients, for whom she is contracted to provide a service, and the time they spend in the home each week. (Previous timescale of 30/06/06 not fully met). DS0000027715.V310656.R01.S.doc Version 5.2 Page 25 Requirement 2 3 YA5 YA6 5 (1) (b) 15 (2) 4 YA24 16 (1) 4 (1)(b) Sitara Haven 5 YA32 18 (1) (a) 6 YA39 24 (1) (2) 7 YA42 13 (4) (c) Information must be provided on 30/11/06 the number of service users and clients in the home, and the staffing levels provided to meet their needs. The Registered Provider/Manager 30/11/06 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. (Previous timescale of 31/07/06 not fully met). Legionella testing must be 30/11/06 carried out on a regular basis. 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 YA22 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 staff team encourage service users to understand more fully the procedures for making their concerns and complaints known. Sitara Haven DS0000027715.V310656.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West London Area Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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.V310656.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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