Inspection on 21/07/06 for 17-19 Edgeware Road

This inspection was carried out on 21st July 2006.

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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

17-19 Edgeware Road 11/01/06

17-19 Edgeware Road 06/07/05

17-19 Edgeware Road 17/01/05

17-19 Edgeware Road 06/07/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 17-19 Edgeware Road Staple Hill South Glos BS16 4LZ Lead Inspector Grace Agu Key Unannounced Inspection 20th July 2006 09:30 17-19 Edgeware Road DS0000003375.V304544.R01.S.doc Version 5.2 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 17-19 Edgeware Road DS0000003375.V304544.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 17-19 Edgeware Road DS0000003375.V304544.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 17-19 Edgeware Road Address Staple Hill South Glos BS16 4LZ 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) 0117 957 0404 0117 9570404 admin@aspectsandmilestones.org.uk Aspects and Milestones Trust Ms Rachel Hicks Care Home 17 Category(ies) of Learning disability (17), Learning disability over registration, with number 65 years of age (17) of places 17-19 Edgeware Road DS0000003375.V304544.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate up to 17 persons aged 19 years and over requiring personal care. May accommodate one named person with a Physical Disability (PD). Will revert back to LD when named person leaves. 11th January 2006 Date of last inspection Brief Description of the Service: The houses at 17-19 Edgware Road are properties run by Aspects & Milestones Trust, which is referred to in the report as The Trust. The houses at 17-19 Edgware Road were first registered as a nursing home for people with learning disabilities. However the registration changed in 1996 with the changing needs of service users to that of a Care Home. The houses are purpose built with off street parking. The Home is registered for seventeen people. The Edgware Road accommodation consists of seventeen single rooms split between the two houses. These are separately run. Each has it’s own staff group and is independent of the other with it’s own kitchen, dining /lounge and bathing facilities. There is a garden at the rear of the building that provides a small paved area for each house. Beyond this there is a larger, shared garden. The home is in a quiet cul-de-sac in a well-established residential area. The shopping area of Staple Hill is very close by with full public amenities. Staple Hill is on a main bus route to the city of Bristol. 17-19 Edgeware Road DS0000003375.V304544.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which took place over five and a half hours and was undertaken to review the care practice to ensure that it is in line with the legislation and that best practice is being followed at the Home. It was also undertaken to review the requirements made at the last inspection to ensure that they have been met. As a part of this inspection one immediate requirement was made in relation to staff undertaking fire drills to ensure that all staff are familiar with actions to be taken to protect the residents in event of fire emergency. A tour of the building was undertaken and a number of records were viewed. Three residents and five staff members were spoken with during the inspection. What the service does well: Generally the Home was found to be clean, tidy, and warm with a good atmosphere. The residents looked well cared for and staff were noted respecting and acknowledging each resident’s individuality in different ways. During a discussion with the two senior staff members met on the day, they stated and it was also evident that the Home provides person centred care planning for all the residents. Residents’ families, friends and visitors compliment on the atmosphere and homeliness Edgware Road offers for its residents. Residents are naturally included in conversations and everyday running of the home, residents are also supported to make every day choices based on individual risk assessments. At a telephone conversation with the manager, she stated that staff work as a team to provide quality care, which supports individuals who have very complex needs, often dealing with extremely diverse behaviour. All staff remain positive and flexible when meeting a new challenge. At the first signs of an individual needing more support, interventions are put in place, and care plans are reviewed, all staff are aware of how to access other agencies for support. Staff are good at supporting each other. The manager also stated that Edgeware Road maintains a happy household, which feels like home. 17-19 Edgeware Road DS0000003375.V304544.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. 17-19 Edgeware Road DS0000003375.V304544.R01.S.doc Version 5.2 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 17-19 Edgeware Road DS0000003375.V304544.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 17-19 Edgeware Road DS0000003375.V304544.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are assesed before admission to the home. EVIDENCE: Whilst the Home had no recent admissions, it was evident from the files reviewed that the Home’s process of admission is comprehensive. Residents are assessed before admission through the Social Services Care Management Team. The home ensures that a detailed individualised care plan is in place for all assessed needs. A copy of the Terms and Conditions of their stay were noted in the care files viewed. 17-19 Edgeware Road DS0000003375.V304544.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 8,9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with individualised care plans and are supported in decision-making processes at the home. EVIDENCE: Three residents care files were viewed. Each care file had care plans developed by the key workers with the involvement of the service user. These care plans had clear details of the needs being met. On the day of inspection some residents were noted having personal care independently and at the time of their choice. At a discussion, staff spoken with stated that recent strategies put in place for managing a resident with long standing challenging need has been successful. The resident is much calmer and less challenging. The home had a confidentiality policy. 17-19 Edgeware Road DS0000003375.V304544.R01.S.doc Version 5.2 Page 11 Residents access the local community with the support of the key workers, risk assessments and risk management strategies. One resident informed the inspector that staff accompany them to the local shops for shopping. On the day of the inspection residents were noted moving around the home without restrictions. One resident stated that they sometimes go out to see friends and come home later. This clearly demonstrates the home has good risk management strategies enabling the residents to exercise their freedom of choice. The home had a missing persons policy in place. Staff were noted interacting with residents in a sensitive and dignified manner and were able to demonstrate good understanding of the needs of the residents. 17-19 Edgeware Road DS0000003375.V304544.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to engage in leisure activities. Healthy diet is provided and residents’ rights are respected. EVIDENCE: From information on care files and discussion with residents and staff, it was evident that residents are encouraged to lead active lives based on individual risk assessments and capabilities. One resident was noted being supported to go out with Day Centre staff. Another resident stated at a discussion “I have just been out to the park for two hours”. Other activities attended by residents included Aromatherapy, games, bowling, Bingo. At a discussion two staff members stated one resident with long-term challenging issues is now more stable and more sociable following new proactive approaches to the individual’s daily activities. 17-19 Edgeware Road DS0000003375.V304544.R01.S.doc Version 5.2 Page 13 The person now attends regular Day Centre sessions and recently secured a cleaning job and is paid a small token payment by the home as an incentive. Each resident had a different day of attending external activity and are encouraged to participate in activities at the home on the days staying at home to foster relationships. Residents continue to maintain family contacts, evidence from the visitors’ book showed that residents receive regular visitors. Two staff members met on the day stated that residents were involved in the planning of the menu. A two-week menu viewed contained nutritious meals. The inspector noted there was a specific menu for a service user with Rheumatoid Arthritis. This is commended. Residents were noted eating their lunch, the meal looked nutritious. One resident spoken with stated that they always enjoyed their meals at the home. The home has two kitchens that were found clean and tidy. The fridge and freezer temperature records were up to date. The laundry area remains satisfactory. 17-19 Edgeware Road DS0000003375.V304544.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20,21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive preferred support as required, their emotional and physical health needs are met, also respect is given to their wishes in the event of death. Medication practices at the home protect the residents. EVIDENCE: The care files reviewed described detailed evidence of the level of support each individual receives at the Home in relation to their personal care. Care plans describe the level of support for individuals living and how the care needs were being met. Examples of comments made by residents in relation to personal care include “ staff look after me well” “Staff Know what I need”. I can get up when I like” Residents who are able are supported to administer their own medication with appropriate risk assessment A planned medication review was carried out at this inspection following concern about four Regulation 37 notifications in relation to medication discrepancies at the home. 17-19 Edgeware Road DS0000003375.V304544.R01.S.doc Version 5.2 Page 15 It was satisfying to note that measures have been put in place to prevent further occurrence and an example of such measure included an activities book for medication to enable the staff on duty to cross check with the medication administration Record Sheet with each other to ensure that errors are detected and eliminated on time. Minor short-falls noted on the day were remedied before the inspection was completed. There was evidence that residents have access to General Practitioner and other health professionals and are supported by the home to attend outpatient appointments whenever the need arose. Care files reviewed evidenced regular medication reviews. The home had a Death and Dying policy and detail in the event of death was noted in some service users’ files. 17-19 Edgeware Road DS0000003375.V304544.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are enabled to complain however the procedure fails to offer options for unsatisfactory complaint outcome. EVIDENCE: The home had a complaints procedure however this was not displayed in the hallway of the two houses or any of the offices. Whilst the complaints procedure seen was produced in the format suitable to the category of the residents it had no telephone number and address of the Commission for Social Care Inspection to enable the residents and or their representatives to contact the Commission if they were not satisfied with the outcome of their complaint to the organisation. It was disappointing to note that the requirement made at the last inspection in relation to the above had not been met. The requirement remains in place. The home is reminded that failure to meet a requirement could lead to enforcement action. The complaint book showed a recorded complaint on 24/04/06 by a resident against another resident in relation to an unsatisfactory behaviour. There was no evidence of how the complaint was resolved and if the complainant was satisfied with the outcome. The home must ensure that all complaints are satisfactorily investigated and appropriately recorded. 17-19 Edgeware Road DS0000003375.V304544.R01.S.doc Version 5.2 Page 17 One bank staff that has been working at the home for five months stated that they would support the resident to complain using a listening technique and ensure that it is accurately documented and pass it on to the manager or any senior staff member. The staff have attended training on abuse and are aware of their responsibilities in regard to dealing with bad practices. The home has the South Gloucestershire policy on reporting abuse as well as that of Aspects and Milestones. 17-19 Edgeware Road DS0000003375.V304544.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a homely environment, specialist equipment is provided to the residents to maximise their independence. However, some areas of the environment are not in a good state of repair. EVIDENCE: The home was clean, tidy and free from offensive odour. A few months before the inspection a request was made by the previous manager to the Commission for Social Care Inspection to convert a disused kitchen into an extra office for staff and a disused toilet into an additional storage space. This request was approved based on the information provided at the time. At this inspection residents spoken with stated that they were aware of the conversion and that this had not had an adverse effect on them in terms of space and toilet facilities. 17-19 Edgeware Road DS0000003375.V304544.R01.S.doc Version 5.2 Page 19 Two staff spoken with stated that the conversions had created more space for staff in terms of better record keeping and privacy and extra food storage for the residents. Both areas were viewed and were noted to be satisfactory. Domestic staff were noted performing their jobs competently and the cleaning liquids were satisfactorily stored in compliance with the last inspection requirement. Records viewed were in date. The kitchen was noted to be clean and the cooker in no17 had been replaced following detected smoke due to a build up of grease underneath the previous cooker. A risk assessment was also noted. The fridge temperature records were up to date. Residents spoken with stated that they were satisfied with their rooms. Whilst the home was noted to be generally clean. The carpets in the hallway at no 17 ground and first floor were noted to be worn and deeply stained. A requirement has been made for the home to replace or deep clean these carpets in order to provide the residents with a better and more comfortable environment. Hand and grab rails were noted in the corridors and bathrooms to aid residents’ mobility. 17-19 Edgeware Road DS0000003375.V304544.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has skilled and competent staff that are regularly supervised to meet the needs of the residents, However it failed to provide appropriate induction to an identified “bank” staff member. EVIDENCE: Evidence from the staff rota reviewed showed that the home had sufficient numbers of staff to meet the needs of the residents living at No 17-19 Edgware Road. Staff met on duty demonstrated good knowledge of the needs of the residents and were observed interacting with residents in a dignified and respectful manner. One staff member was noted using their professional judgement to deal with a resident with challenging behaviour. One member of staff at a discussion described a “guardianship order, the role of staff and how the resident is supported to comply and the consequences if the agreement is broken. One resident spoken with stated “ staff are good and kind to us”. 17-19 Edgeware Road DS0000003375.V304544.R01.S.doc Version 5.2 Page 21 There was evidence of staff training to include, First Aid, Valuing People refresher training, Protection of Vulnerable Adults from Abuse, fire safety and manual handling. One member of ‘bank’ staff met on the day stated that they had been at the home for five months and had attended two weeks induction and drug competency training to enable them to perform their duties effectively. Another temporary staff member spoken with stated that they attended oneday induction and had worked five shifts at No 19. This individual was unable to describe how an identified resident’s need was being met. The home must ensure that all temporary staff are properly inducted to ensure that residents needs are met. Recruitment procedures were noted to be satisfactory. Staff spoken with and evidence from the records seen showed that staff have received supervision regularly. 17-19 Edgeware Road DS0000003375.V304544.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38 39,40, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home benefits from good leadership and management. However, it fails to protect the residents by lack of regular fire drills. EVIDENCE: Rachel Hicks was recently registered as manager of 17-19 Edgeware Road Care Home after a successful “Fit Person’s Interview” at the Commission for Social Care Inspection. Rachel was the deputy manager at Edgware Road before this appointment and has good knowledge of the needs of the residents and is well qualified to run the home and meet its objectives. The Registered Manager has recently commenced the Registered Manager’s Award course, has completed four units and has also applied for courses around management. 17-19 Edgeware Road DS0000003375.V304544.R01.S.doc Version 5.2 Page 23 The manager stated that two recently appointed assistant managers have also commenced the above course to ensure that the management team is well trained. Evidence from service users and staff showed that the manager had an open door policy and is easily accessible to service users, families and staff. Staff met on duty made positive comments about the new manager and how they will support her in the new role to ensure that the residents continue to enjoy good care and that the homely atmosphere is maintained at the home. One resident at a discussion stated, “ I trust Rachel. I am fond of Rachel”. The manager was unavoidably absent on the day however, two senior staff members met on the day showed satisfactory leadership qualities and assisted professionally with the smooth running of the home and the inspection process. This clearly demonstrates that the management of the home is based on good foundation and staff are clear of their responsibilities in the absence of the manager. The two staff met on duty on the day stated that the home reviews its quality of service through regular care reviews with key workers, regular staff development through courses to enable senior support workers to perform their duties effectively. Person Centred planning meetings with support staff are held and also general staff meetings. There are team days to discuss residents’ needs and to ensure that there is a consistent approach. Day care trial reports and day care reviews are regularly checked. The Home regularly interacts with residents formally and informally to inquire how they feel about the services. Families are contacted over the phone to check if they are satisfied with the services provided. The fire log-book was found to be satisfactory. However it was noted that the requirement made at the last inspection in relation to staff attending regular fire drills to familiarise themselves with the procedures in actual fire emergency had not been met. Another immediate requirement was made. An action plan on how this requirement was met was received at the Commission for Social Care Inspection within the time-scale set. The maintenance book was viewed and was found up to date. It was noted whilst reviewing the health and safety service records that staff had raised concern in relation to the frequency of the passenger Lift breakdown. 17-19 Edgeware Road DS0000003375.V304544.R01.S.doc Version 5.2 Page 24 The response from the maintenance manager explaining what action had been taken to deal with the situation was seen in the file. The Accident book showed that accidents were recorded and reviewed and Regulation 37 notifications are sent to the Commission as appropriate. A review of residents’ money showed that the amount recorded in the book tallied with the amount in the safe. All resident information was securely locked away. The Home has policies and procedures to include missing persons, managing aggression and protection of vulnerable adults from abuse that are regularly reviewed in line with changes at the Home 17-19 Edgeware Road DS0000003375.V304544.R01.S.doc Version 5.2 Page 25 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 Standard No Score 1 X 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 3 X 2 X 17-19 Edgeware Road DS0000003375.V304544.R01.S.doc Version 5.2 Page 26 NO 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 2 3 4 Standard YA24 YA35 YA42 YA22 Regulation 23(2) (b) 18 23 22 Requirement Ensure that the deeply stained and worn carpets in No 17 are replaced or deep cleaned. Ensure that identified bank staff receive appropriate induction. Ensure that staff attend regular fire drills. Include the name, address and telephone number of the Commission for Social Care Inspection in the Complaints procedure. Timescale for action 21/10/06 21/08/06 28/07/06 21/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 17-19 Edgeware Road DS0000003375.V304544.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 17-19 Edgeware Road DS0000003375.V304544.R01.S.doc Version 5.2 Page 28 - 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. 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