Inspection on 18/07/05 for The Haven

This inspection was carried out on 18th July 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 but made no statutory requirements on the home.

Other inspections for this house

The Haven 09/07/07

The Haven 11/07/06

The Haven 07/10/05

The Haven 14/12/04

The Haven 01/07/04

The Haven 15/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE The Haven 218 Worcester Road Droitwich Spa Worcestershire WR9 8AY Lead Inspector Andrew Spearing-Brown Unannounced 18 July 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. The Haven E52 S18686 The Haven (Droitwich) V239204 180705.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Haven Address 218 Worcester Road Droitwich Spa Worcestershire WR9 8AY 01905 772240 01527 570238 simongreaves1970@aol.com Mr Simon Greaves Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Simon Greaves CRH 16 Dementia - over 65 16 Old age 16 Physical disabilities - over 65 16 Category(ies) of DE(E) registration, with number OP of places PD(E) The Haven E52 S18686 The Haven (Droitwich) V239204 180705.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: There are no other conditions of registration other than those refered to on the previous page of this report. Date of last inspection 14 December 2004 Brief Description of the Service: The Haven is an adapted care home located on a main road in a residential area close to the centre of Droitwich. The home provides personal care for a total of sixteen people over the age of 65 years. The home is able to provide long term and short-term care for older people who are physically disabled and older people who have a dementia illness. The home is owned and managed by an experienced registered provider. The home’s purpose is to provide a high standard of personal care in a homely environment The Haven E52 S18686 The Haven (Droitwich) V239204 180705.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over a 3 hour period from early afternoon onwards. The previous full inspection took place during December 2004. The main focus of this inspection was to assess the progress made in relation to the requirements from the last inspection. On the day of this inspection the deputy manager was on duty, with one carer. The registered provider was away on a few days holiday. Limited consultation with some residents took place Many areas of the home were seen including some bedrooms and all communal rooms. The care records of a small sample of residents were seen. Other documents seen included medication records, some service records and fire records What the service does well: What has improved since the last inspection? Since the previous inspection care plans are more detailed, however additional elements of already identified care needs also require a care plan to be in place. Further improvement had taken place since the last inspection regarding the administration and recording of medication. A few further improvements are necessary in order to achieve full compliance. The Haven E52 S18686 The Haven (Droitwich) V239204 180705.doc Version 1.40 Page 6 The programme commenced by the registered provider to fit suitable covers to radiators remains incomplete. 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. The Haven E52 S18686 The Haven (Droitwich) V239204 180705.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection The Haven E52 S18686 The Haven (Droitwich) V239204 180705.doc Version 1.40 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 standard(s) 3 Information contained within the pre–assessment documentation was not sufficient to allow a care plan to be developed therefore placing residents at risk. EVIDENCE: Daily records and some other information were available to staff in relation to a newly admitted resident. However no pre admission assessment had taken place. An assessment document was completed after the resident was admitted into the home, however it contained very basic information and failed identify how care needs were to be met and individual preferences. The space available for recording information was minimal. Comprehensive preadmission assessments are vital procedures to undertake to ensure that the home can meet the needs of prospective residents. The Haven E52 S18686 The Haven (Droitwich) V239204 180705.doc Version 1.40 Page 9 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 standard(s) 7, 8 and 9 Some progress has been made in improving the quality of care plans. However suitable and sufficient risk assessments are not in place to ensure safe working practices, which include moving and handling. The lack of these assessments can place both residents and staff at risk of injury. The Haven has made some further progress with regard to the administering and record of medication; further improvement is needed to fully safeguard residents. EVIDENCE: Individual care plans were available and had improved since the last inspection. They contained some detailed information to assist care staff provide a consistent and planned care package. Regular reviews of care plans are now taking place. Care plans were not in place for all areas listed under standard 3.3 of the National Minimum Standards such as oral hygiene or foot care. For these areas an over reliance of staff knowledge was required. Shortfalls were identified in relation to risk assessments, which were not in place in areas such as the risk of falling and the risk of pressure sore. Risk The Haven E52 S18686 The Haven (Droitwich) V239204 180705.doc Version 1.40 Page 10 assessments need to be in place regarding moving and handling and the use of equipment such as bath hoists. Environmental risk assessments were not available for inspection. Nutritional screening is not taking place. Residents are weighed, however the care plan of one resident showed that due to her inability to weight bear she could not be weighed. Suitable equipment needs to be available for staff members to take residents’ weights such as sit on scales. Improvement was noted in relation to the administration and recording of medication since the last inspection, for example the number of gaps during the previous months MAR (medication administration record) sheets was minimal. Further improvements are however needed in order to fully meet the required standard, for example, written confirmation is needed for medication changes given over the telephone and two members of staff need to initial handwritten changes to the MAR sheets. The controlled drug books are unsuitable for purpose and should therefore be changed as previously recommended. The Haven E52 S18686 The Haven (Droitwich) V239204 180705.doc Version 1.40 Page 11 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 standard(s) 12 and 15 There was no written evidence that residents are able to take part in meaningful activities to enhance daily living and quality of life. EVIDENCE: The provision of activities is generally on a add hoc basis and not on any planned arrangement with the sole exception of a person who visits to play the organ once per month. Due to a lack of participation the registered provider has recently discontinued a regular music and movement session. No records existed of any activity or who had taken part and therefore it was not possible to assess the suitability of events, which do take place. No meals were seen as part of this inspection. Residents consulted were complimentary regarding the food available. Afternoon tea consisting of banana sandwiches and scones was prepared and within the fridge. The Haven E52 S18686 The Haven (Droitwich) V239204 180705.doc Version 1.40 Page 12 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 standard(s) 16 and 18 The adult protection procedure is in need of amending and staff need to receive suitable training to ensure that residents are not at risk. EVIDENCE: The complaints log was not available for inspection although it was reported that nobody had voiced any complaint since the previous inspection. The whistle blowing policy needs to be amended in that it makes reference to the former NCSC rather than the CSCI. Furthermore it does not give details of the adult protection office employed by Worcestershire County Council. Training for staff has not yet taken place however it was evidenced that this is due to take place at some point in the future. The Haven E52 S18686 The Haven (Droitwich) V239204 180705.doc Version 1.40 Page 13 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 standard(s) 19, 20, 21, 23 and 25 Communal areas of the home provide an environment that is homely and safe to live in. Improvements in bathing facilities have taken place to make these facilities more comfortable. EVIDENCE: This inspection took place during a very warm period of weather; therefore areas such as lighting and heating were not accessed. It was noted that the home was clean and had no unpleasant odours. An officer from Wychavon District Council Environmental Health Department visited in January 2005 a couple of areas of improvement were noted. The communal lounge and a smaller lounge are well maintained, well furnished and homely in appearance. The dining area is located with a conservatory and therefore bright and particularly warm during this inspection. The Haven E52 S18686 The Haven (Droitwich) V239204 180705.doc Version 1.40 Page 14 A stair lift is fitted to give access to the first floor of the building, although not to a bathroom and toilet. Several residents’ bedrooms were viewed. One bedroom has some new matching furniture, which looked pleasant. Double bedrooms had matching covers on the beds. Some furniture in other bedrooms needs to be replaced in the future. The wash hand basins in some bedrooms were without a plug. Wardrobes are not secured to the wall to prevent them accidentally falling over. A routine maintenance and renewal document was not sought. It was noted that a pressure-relieving mattress was in place on one bed, however it was not a full mattress and designed to be used as an overlay mattress. A risk assessment is needed or alternative equipment should be sought if it is found that the correct use of this equipment makes the bed too high. Over recent months the registered provider has fitted covers to a number of radiators. Some radiators remain uncovered, suitable action needs to be taken to complete the programme to fully safeguard residents against the risk of scalding. No environmental risk assessments are in available, these documents need to be readily accessible to staff. It was noted that communal facilities as well as all the bedrooms viewed possessed liquid antiseptic soap in line with infection control policies provided by Herefordshire and Worcestershire Health Authority. The upstairs bathroom was recently refurbished with a new bath and a hoist fitted over it. The toilet next to this bathroom is not ideal due to the way that the door opens; the wallpaper in this toilet is stained. One of the downstairs toilets had no lock fitted on the door. The Haven E52 S18686 The Haven (Droitwich) V239204 180705.doc Version 1.40 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of the standards in this section were assessed in any detail as part of this inspection due to the lack of availability of the necessary documentation. As a result these standards will be assessed as part of a forthcoming inspection at The Haven. EVIDENCE: No staff rota was available; a current rota showing staff to be on duty and their role must be available for reference and the purpose of inspection. The deputy manager and one carer were on duty during the period of this inspection. Similarly no training records were available during this inspection. The Haven E52 S18686 The Haven (Droitwich) V239204 180705.doc Version 1.40 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36 and 38 Due to the unavailability or insufficient recording regarding a range of areas including health and safety at The Haven, the home failed to demonstrate that residents and staff are free from risk. EVIDENCE: No certificates or other documentation was available to indicate that gas equipment and appliances and the hoists over the baths had been serviced in line with relevant regulations. Copies of these documents need to be forwarded to the CSCI in order to demonstrate compliance with regulations. Portable electrical appliances were last tested at the end of March 2004. The Electricity at Work Regulations require that all equipment is properly maintained and safe for use therefore an effective way to achieve this requirement must be in place. The Haven E52 S18686 The Haven (Droitwich) V239204 180705.doc Version 1.40 Page 17 The registered provider has recently commenced a system to record and monitor hot water temperatures to ensure that the thermostatic values are functioning correctly. Shortfalls were identified within the fire logbook. The weekly testing of the fire alarm was unsatisfactory in that periods when no test took place were evident for example during May when only one test was recorded. The fire alarm was however tested in sequential order as required. Other tests or visual checks were satisfactory and at times in excess of the minimum requirements. No fire drills have taken place. A fire door identified as part of the previous inspection as needing adjustment to ensure that it fully closed into its rebate remains in need of this work. The lower part of this door appears to have warped. A number of fire doors such as those leading into communal areas and the kitchen, continue to be propped open. Evidence of a fire extinguisher used to prop open a door was also noted. The registered provider was required to take action within set timescales to resolve matters highlighted above in relation to fire safety. No training records were available for inspection to demonstrate when staff last undertook both mandatory and good practice training. Training in risk assessment and moving and handling due to have taken place recently were cancelled. The registered provider is the only first aider working within the care home. Recent accident records were viewed; one incident was not recorded upon the handover sheets, which are used as a daily diary while other information recorded was not in line with the verbal information given surrounding a resident’s medical condition. First aid items were noted to be available as required. The required health and safety poster was displayed. The kitchen window was fully open; despite previous assurances no fly screen is in place therefore allowing flying insects access to food preparation areas. Windows upstairs were found to be fully open; these included bedrooms as well as toilets. The registered provider was required to forward risk assessments to the CSCI in relation to these windows as well as an action plan detailing a timetable for the fitting of the required restrictors to limit the opening to 100mm. A lock on a cupboard in the laundry was broken and in need of repair. The Haven E52 S18686 The Haven (Droitwich) V239204 180705.doc Version 1.40 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 x COMPLAINTS AND PROTECTION 2 3 2 2 3 x 2 x STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 x x x x x 2 x 1 The Haven E52 S18686 The Haven (Droitwich) V239204 180705.doc Version 1.40 Page 19 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 3 Regulation 14 Requirement A written assessment must be completed before the admission of any service user, and in accordance with the requirements of Regulation 14 and Standard 3.3 Care plans must be in place covering all aspects of identified need in accordance with areas listed under standard 3.3. A risk assessment must be carried out in respect of every resident, in respect of all aspects of their lives, and with particular attention to prevention of falls. The registered manager must ensure that service users’ care plans contain information regarding nutritional care needs. The registered provider must ensure that suitable equipment is available to ensure that all residents are able to be weighed safety. Timescale for action immediate and on going 2. 7 15 immediate and on going immediate and on going 3. 7 13 4. 8 17 (1) (a) Schedule 3 (o) 31/08/05 5. 8 14 (2) 30/09/05 The Haven E52 S18686 The Haven (Droitwich) V239204 180705.doc Version 1.40 Page 20 6. 9 13 (2) 7. 9 13 (2) Any verbal changes to medication dosages must be followed up by written confirmation. Manual amendments to MAR (Medication Administration Record) charts must be signed by two members of staff and dated. The registered manager must ensure that a record is kept of meaninful and purposeful activities which take place within the home. The procedure for dealing with suspicions or alligations of abuse must be reviewed. A suitable lock must be fitted to the down stairs toilet. Pressure relieving equipment must be used correctly and suitable risk assessments must be in place. Exposed pipe-work and radiators must be guarded or have guaranteed low temperature surfaces. (This requirement was made during the previous two inspection and continues to be part met. The timescale for action has been further extended by which time all radiators must be suitably covered). immediate and on going immediate and on going 8. 12 15 16 (2) (n) 31/08/05 9. 18 12 13 31/08/05 10. 11. 21 22 12 (4) (a) 16 (2) (c) 31/07/05 immediate and on going 30/09/05 12. 25 13 13. 30 12 18 All members of staff must receive induction training to National Training Organisation specification within 6 weeks of appointment to their posts. (This standard was not assessed 31/05/05 The Haven E52 S18686 The Haven (Droitwich) V239204 180705.doc Version 1.40 Page 21 14. 30 12 18 as part of the inspection carried out on 18 July 05.The timeframe previously set remains - this requirement will therefore be reassessed as part of a future inspection) All members of staff must receive foundation training to National Training Organisation specification within 6 months of appointment to their posts. (This standard was not assessed as part of the inspection carried out on 18 July 05.The timeframe previously set remains - this requirement will therefore be reassessed as part of a future inspection) All staff must have individual training and development assessments and profiles. (This standard was not assessed as part of the inspection carried out on 18 July 05.The timeframe previously set remains - this requirement will therefore be reassessed as part of a future inspection) All the records required by regulation must be fully and accurately maintained within the home in accordance with Regulation 17 and Schedules 1, 2, 3 and 4. Records must be available for the purpose of inspection. The registered provider must be able to demonstrate that all gas and hoisting appliances and equipment are serviced as necessary. A copy of the certificates / documentation must be forwarded to the CSCI The registered provider must be able to demonstrate that E52 S18686 The Haven (Droitwich) V239204 180705.doc 31/05/05 15. 30 18 31/05/05 16. 37 17 (2) Schedule 4 (7) immediate and on going 17. 38 13 31/07/05 18. 38 13 31/08/05 Page 22 The Haven Version 1.40 portable electrical equipment items are maintained and safe to use. 19. 38 23 (4) The registered provider must ensure that the fire alarm is tested on a weekly basis (Previous timescale of immediate and on going not met). The registered provider must make suitable arrangements to ensure that fire doors do not have to be propped open to afford service users ease of passage. The fire door at the top of the stairs must fit into its rebate fully (Previous timescale of 30/04/05 not met). immediate and on going 20. 38 23 (4) 28/07/05 for action plan regarding propped open fire doors. 25/07/05 for fire door not closing into rebate. 30/09/05 21. 38 13 23 All staff must receive up to date mandatory training. The registered provider must ensure that windows are risk assessed and restrictors fitted where there is an identified risk to service users. The lock on the cupboard in the laundry must be replaced. The registered provider must ensure that a health and safety policy specific to The Haven is known to all members of staff and be available for inspection (This standard was not assessed as part of the inspection carried out on 18 July 05.The timeframe previously set remains - this requirement will therefore be re- 22. 38 13 (4) 23/07/05 for risk assessmen ts immediate and on going 31/05/05 23. 24. 38 38 13 13 The Haven E52 S18686 The Haven (Droitwich) V239204 180705.doc Version 1.40 Page 23 25. 38 13 assessed as part of a future inspection) A general risk assessment of the premises and Risk Assessments must be carried out and recorded for all the safe working practice topics referred to in Standards 38.2 and 38.3. (This standard was not assessed as part of the inspection carried out on 18 July 05 as records were not available.The timeframe previously set remains - this requirement will therefore be re- assessed as part of a future inspection) 30/04/05 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 Service users and their representatives should be given information in writing in a relevant language and format (preferably in the service user’s guide or statement of terms and conditions of residence) about how to contact the local office of the Commission for Social Care Inspection and local social services and health care authorities. (Not reassessed on this occasion) 2. 9 The home’s copy of the British National Formulary should not be less than 12 months old (Not reassessed on this occasion) 3. 9 The registered manager should obtain a more suitable controlled medication register. The Haven E52 S18686 The Haven (Droitwich) V239204 180705.doc Version 1.40 Page 24 4. 11 The principles of good care, e.g respect, privacy, dignity etc., should be reinforced by the inclusion of appropriate information in the home’s documentation, particularly the staff induction programme, job descriptions and service users’ guide. (Not reassessed on this occasion) 5. 12 A planned programme of social and leisure activities, in and outside the home, should be developed and circulated to all service users in formats suited to their capacities. The service users’ guide should include information about service users entitlement to bring personal possessions with them into the home, how to contact external agents, e.g. advocates, who will act in their interests, and the service users’ right of access to personal records in accordance with the Data Protection Act 1998, and how access will be facilitated. (Not reassessed on this occasion) 6. 14 7. 8. 26 28 A fly screen should be provided for the window in the kitchen. Arrangements should be made for staff to receive training which will enable a minimum of 50 of the care staff to attain a qualification at NVQ level 2 or equivalent by 2005. The home’s equal opportunities policy should be referred to in the service users’ guide. (Not reassessed on this occasion) 9. 29 10. 31 The registered provider should pursue the training necessary to achieve a qualification at NVQ Level 4 in management and care by 2005 (Not reassessed on this occasion) 11. 32 The registered provider should obtain a copy of and comply with the Code of Practice published by the GSCC setting out standards expected of persons employing social care workers, insofar as the code is relevant to the management of a care home. E52 S18686 The Haven (Droitwich) V239204 180705.doc Version 1.40 Page 25 The Haven (Not reassessed on this occasion) The Haven E52 S18686 The Haven (Droitwich) V239204 180705.doc Version 1.40 Page 26 Commission for Social Care Inspection The Coach House John Comyn Drive, Perdiswell Park Droitwich Road Worcester WR3 7NW 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 The Haven E52 S18686 The Haven (Droitwich) V239204 180705.doc Version 1.40 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!