Inspection on 14/09/09 for The Haven

This inspection was carried out on 14th September 2009.

CQC found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Haven 21/06/10

The Haven 11/06/10

The Haven 12/03/10

The Haven 01/03/10

The Haven 26/11/08

The Haven 04/06/08

The Haven 19/06/07

The Haven 21/11/06

The Haven 29/08/06

The Haven 19/09/05

The Haven 10/12/04

The Haven 27/05/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

Extracts from inspection reports are licensed from CQC, this page was updated on 26/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE The Haven 6 - 10 North Terrace Seaham Durham SR7 7EU Lead Inspector Tom Moody Key Unannounced Inspection 14th September 2009 10:00 DS0000046459.V377595.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. The Haven DS0000046459.V377595.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address The Haven DS0000046459.V377595.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Haven Address 6 - 10 North Terrace Seaham Durham SR7 7EU 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) 0191 5816305 0191 5130377 Haven Hommes 2003 Ltd Manager post vacant Care Home 43 Category(ies) of Dementia (7), Old age, not falling within any registration, with number other category (36) of places The Haven DS0000046459.V377595.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP, maximum number of places: 36 2. Dementia - Code DE, maximum number of places: 7 The maximum number of service users who can be accommodated is: 43 26th November 2008 Date of last inspection Brief Description of the Service: The Haven is a two storey building situated near the seafront at Seaham. It is a well-established care home and can accommodate older people (36), with the addition of a smaller unit for people with dementia (7), making a total of 43 places. Accommodation is provided within single rooms (37) and double rooms (3) each containing washbasins. Toilets and bathrooms can be easily reached from lounges and bedrooms. There are a number of lounge and dining areas and a private garden to the rear of the home. The home benefits from sea views and a promenade walkway to the front across a main road. The current provider is Haven Homes 2003 Limited. The current cost of living at the home ranges between £364 and £412 and does not include hairdressing, chiropody and toiletries. The Haven DS0000046459.V377595.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star adequate service. This means the people who use this service experience adequate quality outcomes. Before the visit: We looked at: Information we have received since the last Key Inspection visit on 26 November 2008. The results of a Random Inspection carried out on 3rd March 2009. How the service has dealt with any complaints since the last visit. Any changes to how the home is run. During the visit we: Talked with people who use the service, relatives, staff, the manager & visitors. Looked at how a meal was served and looked at how staff support the people who live here. Looked at information about the people who use the service & how well their needs are met. Looked at other records which must be kept. Checked that staff had the knowledge, skills & training to meet the needs of the people they care for. Looked around parts of the building to make sure it was clean, safe & comfortable. Checked what improvements had been made since the last visit. We told the manager what we found. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations – but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. What the service does well: The service has a well organised and assertive manager who is making positive changes in the home. The Haven DS0000046459.V377595.R01.S.doc Version 5.2 Page 6 The manager is approachable and makes time for people. The staff are well trained and enthusiastic about their role. Staff spend time interacting with service users. One visitor said, “Staff spend much more time with him here.” Small scale activities take place as well as organised entertainment. Meals are appetising, there are suitable choices on the menu and service users can have a cooked alternative if they wish. One service user said “We get good grub here.” The home has a good system for dealing with service user’s personal allowance. What has improved since the last inspection? What they could do better: The home should provide a suitable contract for service users. Although the manager has stated that new ones are being produced, examples should be available for inspection. The Haven DS0000046459.V377595.R01.S.doc Version 5.2 Page 7 The refurbishment of the home has been going on for an extended period and this has resulted in several outstanding requirements. This work must now be completed if the registered provider is to avoid enforcement action. A planned maintenance programme must take place and defects, such as leaking pipes, should be promptly repaired. Toilet or bathroom doors should be capable of being easily closed and locked to ensure service users privacy and safety. Light levels, in all areas used by service users, must be maintained to National Minimum Standards to avoid disorientation and the possibility of falls. Thorough cleaning of the home should be carried out and sufficient domestic hours provided for this. The laundry should have the right number and design of washing machines to meet the needs of the service users in the home. The service user’s guide and the home’s statement of purpose must be kept updated, produced in a clear, easy-to-read type and written in plain English to ensure it is easily understandable. All representations should be recorded as part of complaints procedures and as a measure of quality control. A more co-ordinated approach to the decoration is needed if the home is to look homely. The colours of soft furnishings do not match the dark grey of the carpet in communal areas and the dining chairs and tables are of different designs. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. The Haven DS0000046459.V377595.R01.S.doc Version 5.3 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Haven DS0000046459.V377595.R01.S.doc Version 5.3 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service users needs are accurately assessed and the home can meet those needs Service users have most of the information they need to make choices. A service user’s guide is available containing information but this could be written in clearer terms. Service users can make a trial visit and are able to make an informed choice about coming into the home. EVIDENCE: The home’s registration certificate is on display but the name of the registered manager is out of date. This must be rectified and the service should contact our registration department to have this updated. The service user’s guide and the home’s statement of purpose were seen during the first visit and had a number of flaws, including out of date The Haven DS0000046459.V377595.R01.S.doc Version 5.3 Page 10 information. However by the time of the second visit to the home the manager had revised and improved these documents. Although this was helpful it would still be useful to review the content and simplify the wording using “plain English” principles. Contracts were not available because these are being produced by a consultancy firm. The manager expects to have these in use within a short time. The assessment of service users is comprehensive. The assessment by the placing authority is available in the care plans and the assessment by the home builds upon this. The home records useful information on service user’s background and life history. There are also good risk assessments made. The manager said that service users can visit the home before they decide to live their. Service user’s confirmed this. One said, “I came to have a look and there were people I knew here.” The Haven DS0000046459.V377595.R01.S.doc Version 5.3 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Each person has a detailed plan, which explains how their care they will be given and people’s health care needs are met. The home has policies and procedures for dealing with medication, to protect service users. Service users feel that they are treated with respect by the staff EVIDENCE: There is a good assessment of service user’s physical, mental and social needs in their care plans. The organisation and recording in care plans has been greatly improved since the last Key inspection. There are still some meaningless comments, such as “Please observe,” but these have been greatly reduced and most recording is more meaningful. This contains information from care specialists from many different disciplines. Records in the care plans indicate service users have access to health services such as hospital specialists, doctors, dentists and other practitioners. The Haven DS0000046459.V377595.R01.S.doc Version 5.3 Page 12 Clear medication records are kept. Staff were seen giving out medicines and this was done correctly and safely. Medicines are stored safely in appropriate cabinets. Staff spoke to service users respectfully and allowed service users time to make choices. Service users were well dressed, in appropriate clothing and were well groomed. This enhanced the dignity of service users. Staff always knocked before entering bedroom doors to preserve the privacy of service users. One toilet door did not close properly and this could impact on the privacy and dignity of service users. The manager ensured this was addressed by the time of the second visit. Likewise two vending machines were placed in the lounge giving it the look and feel of a “canteen.” The manager has arranged for these to be moved to a less intrusive area. The Haven DS0000046459.V377595.R01.S.doc Version 5.3 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The homes provision matches service user’s recreational, social and cultural needs, and helps them maintain contact with the surrounding community. They are able to exercise choice and control over most aspects of their lives and they enjoy nutritious and appetizing food. EVIDENCE: The service user’s bedrooms contain personal items and photographs. One visitor said that the home had improved and compared there relatives experience favourably to another home. She said, “Staff spend much more time with him here.” There is an activities and entertainment schedule displayed on the wall. This did not reflect the activities taking place but staff felt it was not to be followed rigidly and could be varied according to the needs or wishes of service users. Service users were taking part in small scale activities during the time of both site visits. One service user said they, “enjoy a game of dominoes” and that they had won at bingo the previous day. The home has a list of forthcoming The Haven DS0000046459.V377595.R01.S.doc Version 5.3 Page 14 entertainments and the manager said she was in the process of organising a Halloween party. There were two hot choices on the menu including one vegetarian option. In addition to this, some service users had chosen a hot food not listed on the menu but the kitchen was able to provide this. The kitchen has an adequate stock of fresh and dried goods. The home was no longer reliant on “own brands” of food. Service users enjoyed their meal. One said, “We get good grub here.” The home also provides some day care and it is possible this may have intruded upon service users “home”, however service users seemed to enjoy seeing people they recognised from the surrounding area. The Haven DS0000046459.V377595.R01.S.doc Version 5.3 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service users and relatives know how to raise issues and they are confident staff and managers will act on their concerns. Training and procedures ensure service users are protected and that their rights are upheld. EVIDENCE: A written complaints procedure is provided in the statement of purpose and service user guide. However there are no written records of complaints. The advisability of recording concerns was discussed with the manager. Service users and relatives are confident that if they have any concerns they will be taken seriously and will be addressed. Staff said they had received training in Protecting Vulnerable Adults (POVA) and they had a good awareness of these issues. This was confirmed by training records. Recruitment records indicate all pre employment checks are carried out including Criminal Records Bureau, POVA list and previous employers references. The Haven DS0000046459.V377595.R01.S.doc Version 5.3 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a comfortable environment in some areas, although access to all areas is restricted because of ongoing refurbishment. The home has some modern equipment such as ‘profiling’ beds. It is adequately furnished although the décor does not always match. There some areas of the home are clean but there are exceptions. The home is spacious, and meets most of the service users basic needs EVIDENCE: There is an ongoing refurbishment programme but this seems to have been going on for some time. Many areas on the first floor of the home are unusable and inaccessible due to this disruption. At the time of the site visits there was no evidence of this work taking place in these areas. In addition to the access problems related to replacement of flooring, double “Baffle” catches had been fixed to some fire doors on the upper floor. This is potentially dangerous in a The Haven DS0000046459.V377595.R01.S.doc Version 5.3 Page 17 fire situation. The manager arranged for their removal immediately this was brought to her attention. Some of the work that has been started is to meet previous outstanding requirements and the registered providers should ensure this is completed without further delay. Water outlets in the unoccupied area should be run at least once a week, for several minutes, to avoid the risk of bacterial build up in unused water pipes. Further advice on this should be sought from the environmental health department or the local water authority. Worn and dangerous carpets have been replaced but the installation in large areas of charcoal grey “contract” carpet does not make for a “homely” environment. This also clashes with much of the décor in the communal areas. Not all furniture, and fittings, match and different styles of table and chairs are evident. The location of vending machines in this area also seemed ill advised and the manager has had them moved. These defects do not enhance the dignity of service users and does not accord with the ideals expressed in the homes statement of purpose and service user’s guide. As well as this piecemeal approach to procurement, some furniture such as a dining room table and pool table, were found to be unstable at the time of the first site visit. The table had been temporarily (and ineffectively) repaired with tape. Fortunately the manager had addressed these defects by the time of the second site visit. It is not clear if a planned maintenance programme takes place. There is a water pipe in the visitor’s toilet that has been leaking for some time and it has caused the “boxing” around the pipe-work to rot. Access to the laundry included a step and this would be difficult to negotiate with laundry skips. The manager has arranged for this to be ramped to avoid this potential hazard. The laundry is quite compact and has only one washing machine. At the present level of occupancy this may be adequate but if the home were to increase its occupancy this is unlikely to have sufficient capacity to cope. Although the communal areas of the home are clean, a number of areas in the home have accumulations of grime. The floor in the shower room is still badly marked and there were accumulations of dust on the wash hand-basin. This was an observation in earlier reports and has not been satisfactorily addressed. A number of areas in the home have light levels far below that required by the National Minimum Standards. The corridors off the main lobby are dimly lit. Correct lighting is important for the orientation and safety of service users, and The Haven DS0000046459.V377595.R01.S.doc Version 5.3 Page 18 other occupants of the home. This observation was made in earlier key inspection reports and action must be taken to rectify the problem. There were no unpleasant smells in the home during either of the site visits. There is a secure and sheltered patio but there is scope for further improvement in planting and amenities in this area. The Haven DS0000046459.V377595.R01.S.doc Version 5.3 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staffing of the home meets service user’s care needs. They are supported in a safe manner, by staff who are properly recruited, and have the appropriate training. The number of domestic hours allocated for this home is not sufficient to ensure proper cleanliness. EVIDENCE: The number of care hours in the home is suitable. Service user’s needs were being met and care was unhurried and appropriate. It was noted in the previous section of this report that adequate cleaning was not taking place. Although staff may be working hard, the home has only parttime cleaners and there is not a cleaner employed every day. The number of hours allocated for cleaning (145 per month) is far below what is required for a home of this size and layout. This number of hours should be closer to a weekly total. The allocation of hours for domestic staff must be increased and thorough cleaning should be carried out on a daily basis. Staff recruitment procedures have also been improved. Staff records indicate all pre employment checks are carried out including Criminal Records Bureau, Protection Of Vulnerable Adults list and previous employer references. Records also show that staff are interviewed and they receive terms and conditions. The Haven DS0000046459.V377595.R01.S.doc Version 5.3 Page 20 Staff training is much improved. The manager has instituted a training programme including specialist training to meet the diverse needs of the service users. This is well documented in her records and in staff personnel files. The Haven DS0000046459.V377595.R01.S.doc Version 5.3 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users benefit from a qualified manager who promotes their welfare and best interests although there are long standing failures to comply with requirements that predate her appointment. Staff are better motivated and act in service users’ best interests. EVIDENCE: The registered manager is a “well organised” person who has completed the Registered Manager Award. The manager is confident and assertive and acts in the best interests of service users. She should be supported in this and receive the full support of the registered providers, including adequate resources. There are long standing issues with the environment that have resulted in repeated requirements, in past reports, as well as this one. The failure to The Haven DS0000046459.V377595.R01.S.doc Version 5.3 Page 22 comply with these, and issues such as the lack of domestic hours, may indicate that the full support of the registered provider is not always forthcoming. The manager has made a number of improvements in the home especially in the area of training and motivating staff. Record keeping has been greatly improved and the manager’s systematic approach has made information retrieval much simpler. Service user’s personal allowance is kept safely and fully accounted for. Receipts are kept for transactions and two people sign to witness transactions. There are long standing issues relating to the environment that have not been fully addressed by the registered provider and this may affect service user’s health and well being. The Haven DS0000046459.V377595.R01.S.doc Version 5.3 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 1 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 1 2 2 3 3 3 2 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 1 1 x 3 x 3 2 The Haven DS0000046459.V377595.R01.S.doc Version 5.3 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 OP2 Regulation 5 Requirement Service users must have a suitable contract setting out terms and conditions and the costs of these. This is necessary to ensure people can make an informed choice about the home. The service user’s guide and the homes statement of purpose must be kept updated, written in an easy to read type and written in plain English to ensure it is easily understandable. This is necessary to ensure people can make an informed choice about the home. The refurbishment programme must continue as planned. This must be completed to ensure the health and safety of service users and to ensure they are provided with a well maintained place to live. This is an outstanding requirement from earlier inspections. The previous timescale was February 2009. The Haven DS0000046459.V377595.R01.S.doc Version 5.3 Page 25 Timescale for action 27/11/09 2 OP1 5 27/11/09 3 OP19 23 31/01/10 4. OP19 23(2) 5. OP21 23 6. OP25 23 13(4) 7. OP25 13(3) 8. OP26 16(2) 9. OP26 13(3) 10. OP27 18 Areas of the first floor undergoing refurbishment must be completed and this area should be made safe. A planned maintenance programme must take place and defects, such as leaking pipes, should be promptly repaired. This is necessary to ensure the comfort and safety of the homes occupants. Toilet or bathroom doors should be capable of being easily closed and locked. This is necessary to ensure service users privacy and safety. Lighting levels, in all areas used by service users, must be maintained to National Minimum Standards. This is necessary to avoid disorientation of service users and the possibility of falls involving people in the home. Water should be run off from all outlets, on a regular basis, in unused areas of the home. This is necessary to minimise the hazard to the occupants of the home, of Legionella bacteria, or any other harmful organisms building up in the pipe-work. The laundry should have the right number and design of washing machines. This is necessary to ensure the laundry can meet the needs of the service users in a home of this size. All areas of the home must be thoroughly cleaned. This is necessary to minimise the spread of infection and keep the occupants of the home safe. The number of hours allocated for cleaning the home must be adequate to ensure the home is properly cleaned. Cleaning staff DS0000046459.V377595.R01.S.doc 27/11/09 27/11/09 27/11/09 27/10/09 31/01/10 27/10/09 27/10/09 The Haven Version 5.3 Page 26 11 OP33 24(1)(a)& (b) must be on duty every day to ensure adequate standards of hygiene are maintained and service user’s welfare is safeguarded. There must be an annual development plan for the home. This is so that service users can be assured that the home is run in their best interests. Repeated requirement. Previous timescales 31/10/08, 28/02/09 and 30/06/09 27/11/09 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 OP1 Good Practice Recommendations The home’s registration certificate is on display but the name of the registered manager is out of date. This must be rectified and the service should contact our registration department to have this updated. This is to ensure service users have accurate information about the home. All representations should be recorded as part of complaints procedure and as a measure of quality control. 2. OP16 The Haven DS0000046459.V377595.R01.S.doc Version 5.3 Page 27 Command Care Quality Commission Care Quality Commission North Eastern Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.northeastern@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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