Inspection on 19/07/05 for 15-17 Kew Gardens

This inspection was carried out on 19th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

15-17 Kew Gardens 05/12/08

15-17 Kew Gardens 08/06/06

15-17 Kew Gardens 14/11/05

15-17 Kew Gardens 11/11/04

15-17 Kew Gardens 25/06/04

15-17 Kew Gardens 09/02/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 15-17 Kew Gardens West Mead Drive Bognor Regis West Sussex PO21 5RD Lead Inspector Ms G Moorey Unannounced 19 July 2005, V229752 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. 15-17 Kew Gardens H60-H11 S14276 15-17 Kew Gardens V229752 190705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 15-17 Kew Gardens Address West Mead Drive, Bognor Regis, West Sussex PO21 5RD 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) 01243 830214/830242 Royal Mencap Society Mrs Ruth Dukes CRH(PC) Care home only 8 Category(ies) of LD- Learning disability - 8 places registration, with number of places 15-17 Kew Gardens H60-H11 S14276 15-17 Kew Gardens V229752 190705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to 8 male and/ or female service users between the ages of 18 and 65 years in the category of Learning Disability may be accommodated. 2. Up to 2 people may have an additional Physical Disability. 3. Total of 8 service users may be accommodated. Date of last inspection 11 November 2004 Brief Description of the Service: Kew Gardens is situated in a quiet residential area in Bognor Regis. The home provides accomodation for up to eight service users within the catergory of learning disability. Kew Gardens is divided into two self contained units that are linked on the first floor. Four service users live in each unit. Service users are given a range of choices of activities including college. The home provides its own transport. 15-17 Kew Gardens H60-H11 S14276 15-17 Kew Gardens V229752 190705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware the Care Standard Act 2000 and Care homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at 15/17 Kew Gardens will be referred to as both ‘service users and residents’. The inspection was unannounced and took place on the Tuesday 19th July 2005 between the hours of 11.00am to 5.00pm. All eight of the service users were seen throughout the day and the inspector took lunch with two residents and a member of staff. The inspection included a tour of the premises and it’s facilities, with the service users being consulted before their rooms were seen. One of the service users showed his room to the inspector this enabled the inspector to see the personalisation of the room and hobbies of the resident. All of the service users were seen and spoken to however due to the profound learning disabilities it was difficult to ascertain a clear picture of their feelings towards their life and care at the home. The manager and two staff were spoken to at the inspection, whilst staff were also observed carrying out their duties. Records and documentation inspected included: residents files, adult protection records, health and safety records, staff files, and the polices and procedures file. What the service does well: What has improved since the last inspection? 15-17 Kew Gardens H60-H11 S14276 15-17 Kew Gardens V229752 190705 Stage 4.doc Version 1.30 Page 6 Since the last inspection the home has worked upon the recommendations that were made including risk assessments, plans in the event of death, collation of staff records and making sure that relatives and parents were aware of the new complaints procedure. 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. 15-17 Kew Gardens H60-H11 S14276 15-17 Kew Gardens V229752 190705 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 15-17 Kew Gardens H60-H11 S14276 15-17 Kew Gardens V229752 190705 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, The home provides good information for prospective service users and their representatives to make an informed decision about whether or not to move in. EVIDENCE: The home has a new statement of purpose in place that lists the managers’ details and has updated the Commission for Social Care Inspection information in the complaints process. The statement of purpose contains the relevant details pertaining to the provision of care and facilities within the home. The home has a service user guide and new complaints procedure which both have appropriate formats. The complaints process has a cassette tape attached to it in order to provide another avenue for the service users to understand information given to them. 15-17 Kew Gardens H60-H11 S14276 15-17 Kew Gardens V229752 190705 Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 9, There care plans within the service ensuring that staff are able to understand the complex needs and offer consistent care to the residents within the home. The home has a comprehensive set of risk assessments and management strategies in place to ensure staff know how to support the service users to maintain and develop their independent living skills, while so practicable, minimising the risks associated with them engaging in activities and daily life. EVIDENCE: Each of the service has a care plan and these were seen to contain a detailed view of each person’s life and care needs. However some of the care plan sections had not been reviewed since 2003 on others a clear reviewing system had been affectively used. Some of the files clearly needed tidying and archiving. All of the reviews and monthly goal reports need to be signed and dated by the staff. 15-17 Kew Gardens H60-H11 S14276 15-17 Kew Gardens V229752 190705 Stage 4.doc Version 1.30 Page 10 Records of the daily diary sheets were seen within the files very little information is stored and little detail is given of the service users days. It was noticed that some section on the forms had not been completed at all. The care plans were geared towards the months where the service users are attending college and had not been updated to include holiday time. The manager said these were to be completed over the next week. Any restrictions placed on the service users are recorded and risk assessed. Plans are reviewed at the service on a bi-monthly basis and main reviews are conducted every six months these are undertaken by the service as there is little evidence of any social work contact or statutory reviews. Recently the manager has contacted all the Social Service departments involved with the home inviting them to review the service users placements this happened in April. Risk assessments are in place and cover such issues as fire evacuation, road safety, showering, vehicles/travel, slips/trips and falls, abusive behaviour etc. Staff sign to say they have read and understand the assessments. The home has improved the risk assessments from the last inspection and have included the new documents as required. There is a policy in place regarding the use of risk assessments and the reasons for there being in place. 15-17 Kew Gardens H60-H11 S14276 15-17 Kew Gardens V229752 190705 Stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15, 16 The service users’ at the home are offered numerous opportunities to engage in age appropriate activities and education with a strong emphasis on using community based resources. The home has a clear ethos of encouraging contact with family and friends. Some of the service users spend away from the home or at the service with family and friends that encourages and reinforces memories and identity. The home was set up to promote independence and individual choice for the service users. This has been achieved through care planning and risk assessments. EVIDENCE: The service users’ all spend time at college during term time. Courses and time spent at college is designed to fit the needs of each person. At the time of the inspection college had finished and the residents were undertaking different activities although there were no written plans within the service users’ however a plan was seen on the board downstairs. 15-17 Kew Gardens H60-H11 S14276 15-17 Kew Gardens V229752 190705 Stage 4.doc Version 1.30 Page 12 None of the service users work due to their profound learning disabilities. Activities include theatre trips, cinema, swimming, link club, discos, pubs, shopping and walking. Trips in the summer/ holiday time can be either on a one-to-one or with agreed groups and staff. During the inspection the service users were preparing for a Thai night where a member of staff was going to cook a Thai meal and decorate the house accordingly. The service had also planned a fun day that involves other Mencap homes for later in the summer. Their was evidence in the service users rooms that they are able to follow and enjoy their own pursues. One service user loves Jim Reeves and evidence of this was seen and heard in his room. All of the service users are registered to vote and one resident is taken to church on a regular basis. Family contact for the service users is varied due to the age group of the residents as they are all over fifty-five. Three of the service users’ have no family at all and the other residents have a varied amount of contact. Family contact is within the care plans. Currently the home does not have regular use of an advocacy service however they currently have a possible volunteer. The service users’ are able to access the community through different trips and activities. Any relationships that were formed of an intimate nature would be clearly assessed as to any risks or issues of protection due to the complex needs of the service users. Service users rights to individual choice and freedom of movement were clearly affected by their over-riding need for close monitoring and supervision. Service users can be on a 1-1 staff ratio including time spend alone with assigned key workers and relationships are based on an intricate basis of needing to know the resident due to the complex needs of each person. The service users’ all have keys to their own rooms. The residents are supported in all areas but they are able to have a sense of independence through the routines. During the inspection lunch was served and shared it became clear that service users could chose where and what to eat. Observation during the inspection found that the service users are involved and spoken to about issues and their daily life in the home. 15-17 Kew Gardens H60-H11 S14276 15-17 Kew Gardens V229752 190705 Stage 4.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 21 Personal support in the home is offered in such a way as to promote and protect service users’ privacy dignity and independence. The health needs of the service users are well met with evidence of good multi disciplinary working taking place on a regular basis. The home has in place the wishes and guidance for each service user in the event of their death to ensure that each person is treated with dignity and that culturally and spiritual needs are met. EVIDENCE: Records at the home within the service users’ files indicated that each resident was having their personal care needs met and recordings of weight, diet, personal hygiene showed the regular basis on which checks were happening. Each service user has a clear plan and detailed description of how they preferred to receive any personal care needs. All of the service users’ needed some support with their personal care this ranged from full care to encouragement. Each resident has a named key worker but do not have a named person for offering assistance with bathing/personal hygiene. 15-17 Kew Gardens H60-H11 S14276 15-17 Kew Gardens V229752 190705 Stage 4.doc Version 1.30 Page 14 The bathrooms have been adapted for the use of a hoist to meet the specific needs of some of the residents. Training given and identified as having been provided by the staff, showed that specialised knowledge of the resident group being worked with had been given in such areas as communication, epilepsy and manual handling. Records showed evidence of the specialist help that is in place for some of the service users such as Consultant Psychiatrist and Community Team. One service user has regular appointments with a masseur at the local health club for a head and shoulder treatment. All of the service users are registered with a local doctors practice and also have access to a Dentist, Optician and Chiropodist. Appointments are recorded in the health plans in the resident’s main files. The accident and emergency records were up to date and did not indicate any major incidents. There was evidence in place that the wishes of each service where in place in the event of their death. These documents had been previously archived but were now in place on service users files. Training for staff was due on the 10th August 2005 in dealing with issues of ageing and death. 15-17 Kew Gardens H60-H11 S14276 15-17 Kew Gardens V229752 190705 Stage 4.doc Version 1.30 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22, 23 Arrangements for protecting service users’ are satisfactory in keeping residents safe from risk of harm or abuse. Complaints are always taken seriously by the home and a new procedure in place enables the service users more understanding of how to complain and the process used. EVIDENCE: The service has a new complaint procedure which has a cassette attached to it to aid more understanding and independence for the residents if and when they wanted to complain. This was introduced to the service in the last six months. Since the last inspection there have not been any complaints received by the Commission for Social Care Inspection or at the service. The manager has now written and supplied each of the relatives/family members with the new complaints procedure. Records of this were seen on file. The home has a comprehensive collection of procedures for responding to allegations or suspicion of abuse. Including the Local Authority guidance. Staff are trained in dealing with incidents or disclosures of abuse from the residents. A policy document is also available on dealing with aggression. Service users care plans include specific guidance to help staff support service users’ whose behaviour may challenge the service from time to time. 15-17 Kew Gardens H60-H11 S14276 15-17 Kew Gardens V229752 190705 Stage 4.doc Version 1.30 Page 16 Financial plans for each of the service users are in place within the care plan. This states who is the guardian of their money. Full policies are in place regarding the resident’s finances and any bequests or wills. Within the last eight months there have been two adult protection issues one of which has been investigated with the outcome being that the member of staff needed to retake basic training this did happen but the person has since left the service. The other issue is ongoing pending an outcome in the next month the issue was originally seen as an adult protection incident that was appropriately investigated but the issue then became more staff related. The member of staff is still on suspension. The manager notified the Commission of both incidents. 15-17 Kew Gardens H60-H11 S14276 15-17 Kew Gardens V229752 190705 Stage 4.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 26, 27, 28, 30 The home is furnished and decorated to a good standard and is kept clean and tidy ensuring that the residents live in a homely, bright and well kept environment, which suits their lifestyles. However issues concerning staff sleeping-in space and infection control could impinge on this environment if not attended to. EVIDENCE: During the inspection each of the service users’ rooms where seen with their permission. The room presented as very individual and had very personal touches such as photograph of parents that had been requested by the home, from families where parents had died and as a reminder of identity. One service user showed his collection of Jim Reeves records and played one and showed his drawings on his desk. This resident is dependent on his wheelchair and the room felt to be small compared to his possible needs but he feels happy in his room and has made it his own. The home has four bathrooms two upstairs and two adapted rooms downstairs currently both of the showers upstairs do not work and one of the bathrooms downstairs is currently awaiting renovation. The other bathroom has now been 15-17 Kew Gardens H60-H11 S14276 15-17 Kew Gardens V229752 190705 Stage 4.doc Version 1.30 Page 18 renovated to a high standard and the home has hoists in place to facilitate those residents with that specific need. Requests have gone into the housing association whom own the house for repairs and the renovation of the second bathroom to be carried out. The communal areas in the home consist of two lounges, two dinning rooms, and a large garden all of which are in good order. The furniture within the house was chosen with the help of the service users one side is more masculine and the other decorated in lighter more feminine style. This is reflective of the individual residents in each house. In the last report it was highlighted as a requirement that the staff were using the dinning room to sleep-in this was found to be unacceptable due to both the restrictions it placed on the service users and issues of privacy for the staff. This has not yet been addressed yet. However there are plans in place to convert one of the upstairs offices this is planned for next year and the renovation is to be undertaken by the Housing Association. There are two laundry rooms one in each house that are placed next to the kitchen and the staff do not have to walk directly through the kitchen but do enter the far corner of the room to get to the laundry. All soiled washing in put into red alginate bags and sealed before being taken to the laundry. Due to the design of the houses it would be difficult to operate any other system. The laundries are appropriate for the homes use and have hand washing facilities and appropriate flooring. The washing machines have a sluice programme on them and are for industrial use. The home does have full policies covering health and safety issues and do offer training to the staff. During the inspection it was observed that the home did not have adequate storage for infected waste and the bin was overflowing and some bags had been placed on the ground. When questioned the manager said that she had spoken to the company concerned and they would either provide the home with an extra bin or extra clearance date. 15-17 Kew Gardens H60-H11 S14276 15-17 Kew Gardens V229752 190705 Stage 4.doc Version 1.30 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34, 35 The home maintains records and supports and trains the staff to ensure that the residents have all of their needs met and to ensure that they are protected and safe. EVIDENCE: The home has generally good staff records and through the recruitment procedures maintains two references and a CRB check on each member of staff. The home also undertakes to check staff through the POVA system. A recommendation was made in the last report that the staff files needed to contain copies of birth certificates and passports. The manager has collected most of these records but clearly said one or two were still not on file. Staff receive both a job description and contract at the beginning of their employment. Part of the recruitment process is a three- month probationary period that can be extended to six months if needed. There is clear evidence of the training programme in place at the home the staff spoken to confirmed that regular basic training had been offered and undertaken. All the staff had undergone an induction programme this had been recorded and kept within the staff file. 15-17 Kew Gardens H60-H11 S14276 15-17 Kew Gardens V229752 190705 Stage 4.doc Version 1.30 Page 20 There are regular updates to the training programme the next adult protection training is in August 05. NVQ training is offered to all the staff and currently there are staff within the team who have completed NVQ2 and NVQ3 and that some of the staff are undertaking the courses currently. 15-17 Kew Gardens H60-H11 S14276 15-17 Kew Gardens V229752 190705 Stage 4.doc Version 1.30 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 40, The home has a full and comprehensive selection of policies and procedures that offer guidance to the staff and help to ensure safe working practices. EVIDENCE: The home has a full complement of policies and procedures which are produced by Mencap. The policies and procedures are used throughout the Mencap homes. The policies were produced in 2002 and would be due for reviewing over the next year. 15-17 Kew Gardens H60-H11 S14276 15-17 Kew Gardens V229752 190705 Stage 4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 x x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x 3 2 2 x 1 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 x Standard No 31 32 33 34 35 36 Score x x x 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 15-17 Kew Gardens Score 3 3 x 3 Standard No 37 38 39 40 41 42 43 Score x x x 3 x x x H60-H11 S14276 15-17 Kew Gardens V229752 190705 Stage 4.doc Version 1.30 Page 23 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 YA28 Regulation 23(3) (b) Requirement The Registered Person shall provide for staff sleeping accomodation in connection with their work at the care home. The manager needs to ensure the safe storage and regular collection of infected waste. Timescale for action 30th 2. YA30 13 (3) 29th August 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard YA34 YA6 YA40 YA27 Good Practice Recommendations Records in relation to members of staff should include copies of birth certificates and passports. The manager needs to ensure that all of the care plans are kept up to date and reviewed on a regular basis. The organisation should look to review the policies and procedures over the coming year to ensure up to date practice. The manager needs to ensure that the upstairs showers are repaired and that one of the downstairs bathrooms in renovation to the standard of the completed one. 15-17 Kew Gardens H60-H11 S14276 15-17 Kew Gardens V229752 190705 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection 2nd Floor, Ridgeworth House Liverpool Gardens Worthing, West Sussex BN11 1RY 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 15-17 Kew Gardens H60-H11 S14276 15-17 Kew Gardens V229752 190705 Stage 4.doc Version 1.30 Page 25 - 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!