Inspection on 12/01/06 for Lyndhurst Residential Care Home (Orrell Lane)

This inspection was carried out on 12th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 but made no statutory requirements on the home.

Other inspections for this house

Lyndhurst Residential Care Home... 09/09/08

Lyndhurst Residential Care Home... 05/11/07

Lyndhurst Residential Care Home... 16/06/06

Lyndhurst Residential Care Home... 28/04/05

Lyndhurst Residential Care Home... 28/01/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Havenview Care Home 51 Orrell Lane Walton Liverpool L9 8BX Lead Inspector Julie King Unannounced Inspection 12th January 2006 10:30 X10015.doc Version 1.40 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 Havenview Care Home DS0000062401.V277644.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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. Havenview Care Home DS0000062401.V277644.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Havenview Care Home Address 51 Orrell Lane Walton Liverpool L9 8BX 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) 0151 525 2242 Lyndhurst Limited Anne Waldock Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Havenview Care Home DS0000062401.V277644.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. To accommodate one named Adult under the age of 65 years in an overall total of 20 28th January 2005 Date of last inspection Brief Description of the Service: Havenview is a small privately run home in the Orrell district of Liverpool. The home has recently been taken over by a company called Lyndhurst Limited which is a family run business with a home in Wales. The home is set in a Victorian detached property and the rooms are on two floors. The rooms are either double or single and there are enough bathrooms and toilets on both floors to meet the residents needs. The home is staffed twenty four hours a day. The double rooms are used as single at present. However the home can accommodate residents who wish to share. The home is well served by local shops and public transport and there are pubs and restaurants close by. Newspapers are delivered to the home and arrangements can be made for hairdressing and chiropody services for residents as required Havenview Care Home DS0000062401.V277644.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 6 hours during which a full tour of the premises took place, and staff and care records were inspected. The inspector spoke to each of the three staff on duty plus 7 of the 11 residents. The home is registered with the Liverpool/Wirral C.S.C.I. in the name of Havenview, but is known as Lyndhurst by the local Social Services department as a result of the recent purchase of the home. The advertising board of the home, which is situated in the front garden, displays the name Lyndhurst. The actual name of the home will be clarified with the present owners and the Commission so as to accurately reflect the registration details. What the service does well: What has improved since the last inspection? Staff spoken to informed the inspector that they are keen to see standards of care improved in the home and are eager to have a permanent manager who can give clear direction. All residents spoken to on the day of the inspection praised the care staff for their kindness and respect. Residents also stated that staff have built good relationships with them and work hard to improve their quality of life. Some of the residents informed the inspectors that they enjoyed meals served in the home. Drinks and food are available in the home throughout the day. Havenview Care Home DS0000062401.V277644.R01.S.doc Version 5.1 Page 6 The management of the home does encourage prospective residents to stay at the home; or to spend time at the home, possibly having meals, before they move in on a permanent basis. Environmentally the home has improved, especially regarding the kitchen and food store areas. Care plans have also improved and are now more detailed and evidence individualized care needs and delivery. The overall impression was that the home was tidier and much cleaner. What they could do better: 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. Havenview Care Home DS0000062401.V277644.R01.S.doc Version 5.1 Page 7 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 Havenview Care Home DS0000062401.V277644.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4. The homes Statement of Purpose does not provide enough information for prospective residents so they can be clear about the services the home provides to meet their care needs. The lack of specialist care training for care staff may lead to unsafe care practice and could therefore compromise the safety of both residents and staff. EVIDENCE: The homes Statement of Purpose and Service User Guide needs to be updated to include all the documents and records as listed in Schedule 1 of The Care Homes Regulations 2001. The registered person has produced two brochures about the care home, but each one has a different picture of Havenview / Lyndhurst on the front, one of which clearly is not the premises at this care home address. The homes pre admission assessment document has improved since the last inspection, with a newly devised holistic tool now in place for most residents. However this document still does not contain all the required information as listed under Standard 3, and some multidisciplinary healthcare team and social worker assessments were not seen on the residents files. Havenview Care Home DS0000062401.V277644.R01.S.doc Version 5.1 Page 9 The care home caters for personal care only, and does not offer nursing care for residents. The home has wall handrails, ramps for wheel chair access and a lift, which helps residents to access all parts of the building. Currently resident’s specialist care needs include dementia/cognitive impairment, diabetes, stroke, confusional states, and infection with Methicillin Resistant Staphylococcus Aureus (MRSA). However the home does not provide specialist care training for the staff. Specialist care training for staff is required to ensure that the assessed and changing needs of the residents can be met and now must be provided to all care staff in the home. This is a noncompliance from the previous inspection report, and the Commission are now considering enforcement action. Havenview Care Home DS0000062401.V277644.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 & 9. There is a care planning system in place for most residents. This provides staff with the information they need to generally meet most resident’s needs. Medication management was compliant with current good practice requirements and guidelines. EVIDENCE: Some improvements have been made to most of the residents care documentation since the last inspection. This has resulted in the resident’s daily health records being more informative and relevant to the care needs of the resident. The care plans are loosely based on the Roper, Logan & Tierney model of care. Personal support in the home is offered in such a way as to promote and protect the residents’ privacy, dignity and independence. Care plans contained some information as regards to the residents care needs, though more should be documented regarding risk assessments to ensure the safety of the resident. However, risk assessments were in place for falls, Havenview Care Home DS0000062401.V277644.R01.S.doc Version 5.1 Page 11 continence, mental health, bathing, smoking and a night care plan had been developed since the previous inspection. All residents in the home can access their NHS entitlements; and care staff escorts the residents to their hospital appointments. Medication management has greatly improved since the previous inspection, and the medications seen were being managed in accordance with current good practice guidelines. Havenview Care Home DS0000062401.V277644.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 & 15 Links with the local community are good, and support and enrich the resident’s lives. Meals in Havenview are good, offering choice and variety, and cater for resident’s special dietary needs. EVIDENCE: Most of the residents were spoken to during this unannounced inspection, all of whom informed the inspector that they were “asked about what I want to do”, regarding activities, daily choices and things to do. This has been an area for improvement after the previous inspection, and a file containing documented evidence of what activity was offered to residents was seen. The person in charge was reminded about the Data Protection Act 1998 and the importance of keeping each resident’s information, even regarding activities, separate. The rear garden is still not fully accessible due to one of the boundary walls fallen down and not being repaired – identified on the previous inspection report; seven lounge chairs and an old table discarded on the patio area, and uneven flagstones on walkway. The kitchen has shown the biggest area of improvement, with records now being kept of cleaning schedules, temperatures of food, no food out of date, and clean throughout. Havenview Care Home DS0000062401.V277644.R01.S.doc Version 5.1 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 & 18 The lack of progress in training staff in the protection vulnerable adults procedure, plus the lack of senior staff knowledge about the Protection of Vulnerable Adults (POVA) regulations undermines the management of the homes ability to sufficiently safeguard residents. EVIDENCE: The home has a complaints procedure, which is available to all residents and their representatives. Residents spoken to commented that they are confident that should they have concerns they will be listened to, taken seriously and acted upon. There have been no complaints to the CSCI about this service since the previous inspection. After the previous inspection, when the non-compliance regarding lack of POVA training was noted the registered provider was given a timescale and requirements for this to be met. The registered provider attended CSCI Liverpool area office and produced an action plan specifying training for staff, including POVA. The registered provider gave the inspectors a copy of his action plan, which had “immediate and ongoing” for all mandatory training, including POVA. During this inspection there was no evidence of this training being carried out or completed; therefore no evidence that the registered provider had met his own action plan, or complied with the legal requirements of the CSCI. Havenview Care Home DS0000062401.V277644.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 The standard of the furnishings and fittings is inadequate, which potentially places residents, staff and visitors at risk of harm or injury. EVIDENCE: There have been significant areas of environmental improvement, especially the kitchen areas, since the previous inspection. Many rooms have new flooring, and some communal areas have new carpets. Some new furniture has also been obtained, and the front of the building has been painted. There are still some areas that were required in the previous report to be upgraded and/or redecorated, and it was concerning to see some resident’s bedrooms in a very poor state of repair. The main environmental findings were as follows• Huntleigh Porta Hoist in top floor bathroom – no safety certificate, and date of last checking unknown DS0000062401.V277644.R01.S.doc Version 5.1 Page 15 Havenview Care Home • • • • • • • • • • • Top floor bathroom (next to office) full – two bed mattresses, chest of drawers and dressing table next to bath Room 11 – bed against the radiator – the person in charge was asked to move this immediately (again identified on the previous report) Room 8 – Border ripped off wall in places, sink unit badly damaged with damp, table damaged, chest of drawers damaged – all require replacement. This bedroom was identified on the previous inspection Room 7 - Chunks of plaster out of bedroom wall – identified on the previous report Room 6 – Bedrail x 1 in use, with the bed against the wall on the side without the rail – the person in charge was told about the dangers of this and asked to rectify immediately. Fire door next to day lounge – not closing into rebate adequately Fire risk assessment – Not available Communal soaps in all areas Meat temperature probe in ground floor bathroom Communal items, such as ‘Polytar’ in bathrooms Room 5 – curtain rail damaged – outstanding from previous report. The Commission is considering further action if these requirements continue not to be met within the given timescales. Havenview Care Home DS0000062401.V277644.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 & 30. The policy and procedures for the recruitment and training of staff fail to meet the standard required. The training needs of staff must be reviewed to ensure the health and safety of both residents and staff is promoted. EVIDENCE: Currently the home has no registered manager. An acting manager who has worked part time in the home for four years is running the home, but only works night duty; this is inadequate and needs to be addressed as a matter of urgency. The homes policy and procedures for recruitment of staff fails to meet the required standard, and none of the staff spoken to had received copies of their CRB and POVA check which is indicative of one not being done. The staff rota evidenced a very high turnover of staff, with most of the staff that was present at the last inspection now having left. The rota evidenced that there are only eight permanent staff on the rota which is insufficient to cover staff sickness, absence, etc. One of the carers, who are also responsible for doing all the cooking, has not had a day off for well over a month due to no one else being available to cover. Staff personnel files were unable to be accessed due to the person in charge not having keys to the filing cabinet, so it was not possible for the inspector to check references, etc for any staff members. During this inspection, the Havenview Care Home DS0000062401.V277644.R01.S.doc Version 5.1 Page 17 administrator for the home (who is the registered provider’s representative) rang to speak to the person in charge on four occasions. The inspector asked if he would like to speak to her, or join the inspection as some of the required documents and records could not be accessed without him. He declined to speak to the inspector, and did not attend the home whilst the inspection was taking place. He promised to attend the Liverpool CSCI area office the day after the inspection to bring all the missing documentation, but failed to attend or even telephone with an explanation. On the day of the inspection, it was not possible for the inspector to evidence records of staff who had undertaken training for e.g. manual handling, food hygiene, and fire drill practice. The cook also has no current food hygiene certificate. This type of training is essential for the health and safety of the residents and staff, and leaves minimal option for the Commission other than to proceed towards enforcement action. Havenview Care Home DS0000062401.V277644.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36, 37 & 38 There is no leadership, guidance and direction to staff that ensures residents receive consistency of care and are safe in the home. The home does not have a quality assurance process; this results in some practices that do not promote the health, safety and welfare of the people using the service. EVIDENCE: The home does not have a quality assurance process; this results in some practices that do not promote the health, safety and welfare of the people using the service. Havenview /Lyndhurst does not have a registered manager, and the acting manager only works nights. The person in charge on days wants to commence her NVQ in Management in the near future, and certainly appearing to take the leadership role, and has done a good job of updating the management of medications at the care home. Havenview Care Home DS0000062401.V277644.R01.S.doc Version 5.1 Page 19 The inspector was unable to access records of resident’s personal allowances due to these being held by the administrator. This was a requirement of the previous inspection, again not met. Inspection of safety records indicated that regular testing of emergency lighting and fire drills did not always take place within the home. There was no evidence of recent fire training for staff. The gas safety certificate and the NICEIC (electrical safety) certificates, along with a relevant fire risk assessment were not available, nor was the hoist certificate for the ‘Huntleigh Porta’ hoist. These issues were identified on the previous report, and constitute another non-compliance. Havenview Care Home DS0000062401.V277644.R01.S.doc Version 5.1 Page 20 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 X 2 2 X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 X 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 1 1 X X X X X X 2 STAFFING Standard No Score 27 1 28 X 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 3 1 X X 1 1 1 Havenview Care Home DS0000062401.V277644.R01.S.doc Version 5.1 Page 21 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 3& 4 Regulation 18 Requirement The registered person must ensure that Specialist Care Training for staff is facilitated in the care home. A plan of how the training needs of staff are to be addressed must be provided within two weeks of the receipt of this report. Previous timescale of 30.05.05 not met. The registered person must ensure that documention in relation to the Protection of Vunerable Adults is available in the care home. All staff must be informed of the the policy and undertake relevant documented training. Previous timescale of 30.05.05 not met. The registered person must ensure that the premises to be used as the care home are well maintained at all times both internally and externally. The Registered person must(1) Replace all wall coverings that are damaged in the care Havenview Care Home DS0000062401.V277644.R01.S.doc Version 5.1 Page 22 Timescale for action 31/03/06 2 4 & 18 13 31/03/06 3 19 23 31/03/06 (2) home Repair all damaged walls in residents bedrooms Replace of repair all items of damaged furniture throughout the home (3) (4) Repair or replace all broken curtain rails/poles and curtains (5) Dispose of all rubbish and waste from outside the building, and ensure that in future all waste is stored safely and securely. 4 19 23 Previous requirement of 30.05.05 not met. The registered person must ensure that all equipment provided at the care home is maintained in good order The registered operson must obtain safety certificates for all moving and handling equipment and the gas and electrical safety certificates and forward copies of these to the CSCI without delay. Previous timescale of 30.05.06 not met. The registered person must ensure that adequate risk assessments are completed and appropriate action is taken on their findings - specifically there must be risk assessments in place about the use of bed rails and the risks of scalding from hot surfaces such as radiators, and hot water immersion facilites. DS0000062401.V277644.R01.S.doc 31/03/06 5 21 & 38 13 & 23 31/03/06 Havenview Care Home Version 5.1 Page 23 6 38 23 7 31 8 8 1-38 8 9 29 19 10 28 & 30 18 11 31 9 Previous timescale of 30.05.06 not met. The registered person must ensure that suitable adaptations are made, and such support, equipment and facilities are provided to service users; and all equipment is maintained in good working order at all times – refer to lack of LOLER safety certificate for the hoist. Previous timescale of 30.05.05 not met. The registered person must appoint a suitably qualified and competent manager to manage the care home. Previous timescale of 30.05.05 not met. The registered person must carry on or manager the care home with sufficient care, competence and skill. Previous timescale of 30.05.05 not met. The registered person must ensure that all staff recruited to the care home have up to date and valid CRB/POVA enhanced certificate, before being employed in the care home. Previous timescales of February 2005 & 30.05.05 not met. The registered person must ensure that training programmes for staff are provided in the care home to ensure the health and safety of both residents and staff. Previous timescale of 30.05.05 not met. The registered person must ensure the homes acting manager is given training in the management of a care home, and is competent in understanding the National DS0000062401.V277644.R01.S.doc 31/03/06 31/03/06 31/03/06 31/03/06 31/03/06 31/03/06 Havenview Care Home Version 5.1 Page 24 12 33 26 13 36 18 & 24 14 27 18 15 38 23 (4) 16 35 17 17 37 17 Minimum Standards and Care Home Regulations. Previous timescale of 30.06.05 not met. The registered person must ensure that a monthly written report on the conduct of the home isforwarded to the Liverpool/Wirral office of the C.S.C.I. Previous timescale of the 28.02.05 & 30.05.05 not met. The registered person must ensure that documented supervisions for staff are held six times per year. Previous time scale of 28.02.05 & 30.05.05 not met. The registered person must ensure that all staff completes a recognised induction on commencement of employment and records of this are kept. Previous timescale of 30.05.05 not met. The registered person must make suitable arrangements for persons working at the care home to recieve suitable training in fire prevention, and the procedure to be followed in case of fire, including the procedure for evacuation and saving life. Previous timescale of 30.05.05 not met. The registered person must manage all service users monies in accordance with this regulation - refer to lack of documentation regarding service users personal allowances. Previous timescale of 30.05.05 not met. The registered person MUST keep at the care home the documents and records as specified in Schedules 1, 2, 3 & 4 of The Care Homes Regulations DS0000062401.V277644.R01.S.doc 28/02/06 31/03/06 31/03/06 31/03/06 31/03/06 31/03/06 Havenview Care Home Version 5.1 Page 25 18 27 18 2001 (ammended 2004). Previous timescale of 30.05.05 not met. The registered person must ensure that there are adequate staff employed at the care home in sufficient numbers as to ensure the health, safety and welfare of all residents at all times. 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard 1 Good Practice Recommendations It is recommended that the registered person completes another review and update of the Statement of Purpose and Service User Guide to ensure it accurately reflects the current situation at the care home. It is recommended that the water storage facility is tested for Legionella bacteria at least once a year. It is recommended that all activities are clearly documented in resident’s files, rather than in a communal book, which could breach the Data Protection act 1998. 2 3 26 12 Havenview Care Home DS0000062401.V277644.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Havenview Care Home DS0000062401.V277644.R01.S.doc Version 5.1 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. 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