Inspection on 30/09/05 for Sitara Haven

This inspection was carried out on 30th September 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 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 Jane Collisson Unannounced Inspection 30th September 2005 9.35am Sitara Haven DS0000027715.V252968.R01.S.doc Version 5.0 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.V252968.R01.S.doc Version 5.0 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.V252968.R01.S.doc Version 5.0 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.V252968.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th April 2005 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 is 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.V252968.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 30th September 2005 from 9.35pm to 11.45am. The Registered Provider/Manager was present for only a short period as she was due to go out with one of the permanent service users and two day service clients. The second permanent service user was at a day centre. Two members of staff were present. Three Immediate Requirements were made at this visit for the storage and administration of medication and storage of potentially hazardous materials. These had been met by the second visit, which took place on the 5th October at 3pm. During this visit, both of the permanent service users were in the home and were seen in private. The fourth member of staff was also present. Records examined included those for medication, care planning, staff and finances. The inspection took a total of 3.5 hours. What the service does well: What has improved since the last inspection? What they could do better: It was found that the Registered Provider/Manager has admitted service users without the full information which is required to support a good placement, and she needs to ensure that this is carried out in the future. A variation to the category of registration must be made for one of the service users. Although activities are provided for the service users, the Registered Provider/Manager needs to ensure that the opportunities for new activities is provided and new interests encouraged. The medication administration and storage was poor and the Registered Provider/Manager must ensure that she understands fully the need for robust procedures and the legislation governing this. The finance procedures for the service users was not fully understood by the Registered Provider/Manager, who was supporting them, and she must ensure that she has all of the information to carry this out efficiently. Sitara Haven DS0000027715.V252968.R01.S.doc Version 5.0 Page 6 The basic training, supervision and support for a new staff member was found not to have been carried out sufficiently well to demonstrate a good induction. The Registered Provider/Manager must rectify this by providing a thorough induction, training and development programme when new staff are employed. The Registered Provider/Manager has not demonstrated that she is fully conversant with the current legislation and the requirements of the Care Home Regulations 2001. This is an area where she needs to show that she fully understands the implications of poor practice and takes action to comply. The fire signage needs to be checked by the London Fire and Emergency Planning Authority for compliance and the fire risk assessment needs to take into account the potential risks for the two service users who smoke. The Registered Provider/Manager needs to ensure that COSHH materials are safely stored and service users not put at risk. 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.V252968.R01.S.doc Version 5.0 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.V252968.R01.S.doc Version 5.0 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): The information for the service users and their families to know about the services and facilities offered is available but not in formats which would aid the service users to understand it better. EVIDENCE: The Statement of Purpose and Service Users Guide have been produced and have been submitted to the Commission for Social Care Inspection. They are not, however, available in formats to meet the needs of people with learning disabilities, or other languages. This needs to be considered to ensure that all of the information, including the complaints procedure, is accessible to the service users. One new service user was admitted with a needs-led assessment provided by the local authority, but it was not clear how recently the assessment has been carried out and was not sufficiently detailed for the Registered Provider/Manager to make a full assessment. She was asked to ensure that she requests an up-to-date and relevant assessment for any potential service users who are referred by Social Services. The Registered Provider/Manager had not applied for a variation from the Commission for Social Care Inspection for another service user who was admitted outside the category of registration for the home. She has agreed that this will now be done to enable the service user to remain in the home if it is agreed that his needs can be met. Sitara Haven DS0000027715.V252968.R01.S.doc Version 5.0 Page 9 Some specialised training in learning disabilities and mental health has been provided to the staff to support them to meet the service user’s needs. Visits to the home took place for the newest service user prior to a decision was made about placement. The service users both indicated that the home was meeting their needs. Sitara Haven DS0000027715.V252968.R01.S.doc Version 5.0 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): Efforts have been made to improve and develop the care plans and risk assessments for the service users but regular review needs to take place to ensure that any changes needs are reflected. EVIDENCE: Progress has been made in providing care plans for the service users to identify their needs and how they can be met. The care plans for both service users were examined. There was a lack of information from care manager placing one of the service users, regarding previous his placements. Knowledge of these could assist the Registered Provider/Manager in supporting the service user to maintain and develop independent living skills. Both of the current service users are able to make decisions about their daily lives and they confirmed that they are able to choose the activities and the leisure pursuits they enjoy. However, those identified on the needs-led assessment for one of the service users had not yet commenced and efforts should be made to ensure that he has the opportunity to try these again. Although there are only two service users living in the home permanently, the Registered Provider/Manager also has two day service clients, on two days of the week, and occasional weekend respite for one service user. The Registered Provider/Manager’s family also share the home. Regular consultation should Sitara Haven DS0000027715.V252968.R01.S.doc Version 5.0 Page 11 take place with the permanent service users to ensure that these additional services do not interfere with the activities they wish to pursue in the home and that they have the use of sufficient communal space for their needs. The Registered Provider/Manager was required at the last inspection to expand the risk assessments for the service users. Those in place have been improved and have been provided for the new service user. These now need to be seen to be reviewed, along with the care plans, on a regular basis. The service users’ files are kept in the home’s small office and during the visits of this inspection, the Registered Provider/Manager improved the storage of documentation, making it easier to access. Sitara Haven DS0000027715.V252968.R01.S.doc Version 5.0 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): Both service users have the opportunity to pursue activities outside of the home, although this could be developed to assist them to enhance skills and expand their interests. EVIDENCE: Both service users are able to pursue the day activities they enjoy. One prefers to attend a day centre three times a week, which he said he enjoys. The other prefers not to attend organised day activities and goes out with the home’s staff regularly. A number of the activities shown on the initial assessment for one service user have not yet been introduced. These included literacy classes and swimming. It was discussed with the Registered Provider/Manager that the opportunities for service users to be able to develop their interests needs to be demonstrated. A visit to Macdonalds was being planned on the first day of the inspection for one of the service users and the day service clients. Staff said that this is an activity that the service users enjoy as well as drives to various areas in the home’s transport. 13 The home is very close to the amenities and shops of Southall, with easy access to other shopping centres. One service user Sitara Haven DS0000027715.V252968.R01.S.doc Version 5.0 Page 13 particularly likes shopping and his financial records demonstrated that he is able to pursue this interest. The Registered Provider/Manager had offered a short holiday to both of the service users in Blackpool, but only one has chosen to take this opportunity. The Registered Provider/Manager said that it had been very successful. Both service users have family members, who maintain contact and are invited to attend reviews. One service user’s family visit the home regularly. Locked spaces have now been provided for the service users in their bedrooms to enable them to have a private space for personal items. Keys to the bedrooms are provided. There are some restrictions in place regarding areas for smoking, which affects both service users. Both indicated that this was not of concern to them. The Registered Provider/Manager said that both service users respect the restriction on smoking in the lounge/dining room if other people are present who do not smoke. 17. A variety of Asian and English food is offered to the service users and a menu is maintained. One service user said that he preferred not to cook himself and spoke very favourably about the food provided. The staff spoken to were fully aware of his favourite meals. Sitara Haven DS0000027715.V252968.R01.S.doc Version 5.0 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): The medication administration was found to be poor, with the Registered Provider/Manager unaware of the basic procedures to ensure safe storage, labelling and recording of medication. EVIDENCE: The health needs of the service users are recorded in their care plans and evidence was seen that medical appointments with professionals, including the mental health team, are recorded. Training has been provided to all the staff on learning disabilities and mental health needs. Following an examination of the medication, an Immediate Requirement was issued for the medication to be dispensed from bottles and packets and not from unsealed dosette boxes made up by the Registered Provider/Manager and pharmacist, which were both incorrectly labelled. The storage of the medication, in a filing cabinet, was also unsatisfactory and an Immediate Requirement was issued for this to be improved. At the second visit on the 5th October 2005, the Immediate Requirements had been actioned. The Registered Provider/Manager had also purchased a separate cabinet for medication. Although the Manager now keeps stock records of medication received and used, following a requirement at a previous inspection, two errors were found in the number of tablets brought forward. She needs to ensure that she is fully conversant with the Royal Pharmaceutical Guidelines for the Sitara Haven DS0000027715.V252968.R01.S.doc Version 5.0 Page 15 administration of medication and that she maintains accurate records. REQUIREMENT1 21 NA Sitara Haven DS0000027715.V252968.R01.S.doc Version 5.0 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): The complaints procedure is not produced in a format the service users can access and which would encourage them to understand the procedure and voice their concerns. The Registered Manager needs to be aware of the financial arrangements for the service users where she is supporting them to manage their allowances. EVIDENCE: The Registered Manager said no complaints have been made since the last inspection. The complaints policy is not produced in formats to suit the individual needs of the service users, to enable them to better understand the procedures, and it is strongly recommended that this is done. It was a requirement at the previous inspection that, following an allegation which was found to be unsubstantiated, the Registered Provider/Manager and the staff team must undertake all of the specialist training required to meet the needs of the service users admitted to the home, which included Protection of Vulnerable Adults training. This training has not yet been held but the Registered Provider/Manager said that this should take place in the near future. This is an outstanding issue which must be addressed within the timescale. REQUIREMENT The Registered Provider/Manager explained the arrangements in place for dealing with the finances of the two service users and the recording system was examined. The finances of one service user are currently dealt with by the Mental Health team and the Registered Provider/Manager supports the service user to collect the money from the team. She was unsure of the status of the benefits, which included money for taxis to the day centre. The Registered Provider/Manager needs to have in place a procedure for handling Sitara Haven DS0000027715.V252968.R01.S.doc Version 5.0 Page 17 the service user’s finances, which include the purposes for which it is to be used, clarifying these with the service user’s care manager. Sitara Haven DS0000027715.V252968.R01.S.doc Version 5.0 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 the following standard(s): The home continues to be maintained in a reasonable condition and cleanliness has improved. The provision of sufficient communal space for the service users to enjoy their activities needs to be kept under review. EVIDENCE: The two service users have the use of the ground floor lounges, one of which is used as the dining room. Because the home is shared with the Registered Provider/Manager’s family of four, in addition to two day service clients and a respite service user, for part of the week, it needs to be ensured that these are sufficient to meet the needs of the permanent service users. Both tend to use the dining room/lounge, as this is the smoking area, when no other service users are present. Otherwise the garden is used for smoking. It is recommended to the Registered Provider/Manager that the situation is always reassessed at the service users’ reviews to ensure that there are no concerns about this situation. Should the third bedroom be filled by a permanent service users then the situation will need to be reviewed again, particularly if the service user is a non-smoker as this will impact on the space available. The service users’ bedrooms were seen on this inspection and both service users said that they were satisfied with the amenities provided, which include Sitara Haven DS0000027715.V252968.R01.S.doc Version 5.0 Page 19 two comfortable chairs to enable them to entertain visitors. Laminated floors, rather than carpets, have been provided, which the Registered Provider/Manager said better suit their needs. Neither room is fully personalised and it is recommended that further work is carried out with the service users and their representatives to encourage them to improve their environments and provide the opportunity to development any interests and hobbies they may have. RECOMMENDATION Sufficient facilities are provided for the service users to either have a shower or a bath. The ground floor shower room is located off one of the lounges and the bathroom is on the first floor. Neither service users has any mobility problems and no specialist equipment is required. One member of staff was engaged in cleaning the home on the first day of the inspection and it was found to be clean in all areas. Sitara Haven DS0000027715.V252968.R01.S.doc Version 5.0 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 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): The Registered Manager needs to ensure that all of the staff have the basic training required to support the service users and develop their own skills. The current supervision recording does not demonstrate how staff are supported with their work. EVIDENCE: One new, part-time member of staff has been employed in the last four months. An induction checklist was seen to be completed but there was limited content to show the extent of the induction training. The member of staff participated in training for learning disabilities and mental health awareness but has received no other basic training courses. The Registered Provider/Manager said that first aid, epilepsy and food hygiene training are to be booked and the adult protection training is due to be held for all staff. A training and develop programme for all staff members must be in place, particularly those who have no previous experience of care support work. An examination of the files showed that Criminal Records Bureau disclosure and references had been obtained for the new member of staff. Although the records evidenced that the new member of staff had received some formal supervision insufficient recording had taken place to demonstrate that this was of value to the Registered Provider/Manager and the member of staff. A basic induction procedure was seen but there has been lack of basic training for the staff member and the Registered Provider/Manager needs to show that new Sitara Haven DS0000027715.V252968.R01.S.doc Version 5.0 Page 21 staff are fully inducted and equipped with the training and knowledge to meet the needs of the service users and to develop skills. Sitara Haven DS0000027715.V252968.R01.S.doc Version 5.0 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 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): Although progress has been made in some areas of recording and in compliance with the Care Home Regulations 2001, other concerns raised at this inspection regarding medication administration, poor storage of COSHH materials and the lack of training for a new staff member, indicate that the Registered Manager needs to improve the management of the home. EVIDENCE: The staff team has now increased to four, which includes the Registered Provider/Manager and her partner. There was noted to be a good rapport between the staff and the service users. While areas of recording have improved, the medication administration was found to be poor and the Registered Provider/Manager needs to ensure that she is fully conversant with the current legislation and the requirements of the Care Home Regulations 2001. A previous requirement to have the hot water temperatures in the bath and shower regulated to be delivered at around 43° C has been met. The water Sitara Haven DS0000027715.V252968.R01.S.doc Version 5.0 Page 23 checked on this inspection was satisfactory and records have been kept to show that it is tested. The Registered Provider/Manager was required to ensure, at the last inspection, that the fire signage met with the London Fire and Emergency Planning Authority’s requirements. She said that she had not been able to get the fire brigade to visit. She had not requested this in writing and was advised to do so. Both of the current, permanent service users smoke and the fire risk assessment had been updated, in parts, to take this into consideration. As both service users hold their own cigarettes, the assessment must fully document any risk that might be present because of this. The remainder of the fire risk assessment needs to be reviewed regularly and the advice of the London Fire and Emergency Planning Authority sought. REQUIREMENT An Immediate Requirement was issued at this inspection as the storage of the COSHH materials, which are potentially hazardous, was found to be poor, with the cabinets in which the materials was stored left unlocked. When locked, one drawer of the cabinet could still be accessed. The Registered Provider/Manager was required to remove the materials and provide alternative, lockable storage. At the second visit, on 6th October, she was storing the materials in a locked cabinet. REQUIREMENT Sitara Haven DS0000027715.V252968.R01.S.doc Version 5.0 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. 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 3 2 X 3 X Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 X X X 3 3 LIFESTYLES Standard No Score 11 2 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 X 3 X 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sitara Haven Score X 3 1 x Standard No 37 38 39 40 41 42 43 Score 2 X X X X 1 x DS0000027715.V252968.R01.S.doc Version 5.0 Page 25 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 YA2 Regulation 15 (1) Requirement 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. A variation to the category of registration must be made detailing how the needs of the individual service user can be met by the home. The Registered Provider/Manager must ensure that the service consulted about the activities they wish to undertaken that the opportunities for participation are provided. That the medication cabinet to be kept locked at all times and the medication storage to be improved by 6 pm on 30 September 2005. IMMEDIATE REQUIREMENT ISSUED. That all medication is dispensed from the original containers unless a sealed system is used which is filled by the Pharmacist. The medication to be dispensed from its original containers from the next dosage due. IMMEDIATE REQUIREMENT DS0000027715.V252968.R01.S.doc Timescale for action 31/10/05 2 YA2 14 (1) (a) (c) 30/11/05 3 YA11 16 (2) (m) & (n) 30/11/05 4 YA20 13 (2) 30/09/05 5 YA20 13 (2) 30/09/05 Sitara Haven Version 5.0 Page 26 ISSUED. 6 7 YA20 YA23 13 (2) 13 (6) The amount of medication held in stock must be monitored to ensure accurate recording. The Registered Provider/Manager must ensure that staff have the required adult protection training and information. The Registered Provider/Manager must have in place a procedure for handling the service user’s finances, which include the purposes for which it is to be used. All staff must undertake the core training courses, updated as required, and have a training and development programme which evidences this. Staff must receive support through the individual supervision process. 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. The Registered Manager/Provider must enquire from the London Fire and Emergency Planning Authority that the required signage is in place. (Previous timescale of 31/7/05 not met) 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. (Previous timescale of 31/5/05 not fully met) The COSHH materials must be stored in a cupboard which is kept locked and provides secure storage. COSHH materials to be removed to safe, lockable storage. IMMEDIATE DS0000027715.V252968.R01.S.doc 31/10/05 30/11/05 8 YA23 13 (6) 30/11/05 9 YA32 18 (1) (a) 31/12/05 10 11 YA34 YA37 18 (2) 9 (2) (b) (i) 30/11/05 30/11/05 12 YA42 23 (4) (c) (iii) 30/11/05 13 YA42 23 (4) (v) 31/10/05 14 YA42 13 (4) (a) & (c) 30/09/05 Sitara Haven Version 5.0 Page 27 REQUIREMENT ISSUED. 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 YA22 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. That service users are supported to personalise and improve their individual living spaces. 2 YA25 Sitara Haven DS0000027715.V252968.R01.S.doc Version 5.0 Page 28 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.V252968.R01.S.doc Version 5.0 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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