Inspection on 06/06/07 for 4a Ash Street

This inspection was carried out on 6th June 2007.

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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

4a Ash Street 14/10/08

4a Ash Street 15/11/07

4a Ash Street 08/12/06

4a Ash Street 06/12/05

4a Ash Street 26/07/05

4a Ash Street 29/11/04

4a Ash Street 29/06/04

Similar services:

Insight - Eastchurch

Southfields

Thorndene

Sutton Lodge Nursing Home

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

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

CARE HOME ADULTS 18-65 Ash Street (4a) 4a Ash Street Ash Nr Aldershot Hampshire GU12 6LT Lead Inspector Vera Bulbeck Unannounced Inspection 6th June 2007 11:40 DS0000013508.V340673.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 DS0000013508.V340673.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. DS0000013508.V340673.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ash Street (4a) Address 4a Ash Street Ash Nr Aldershot Hampshire GU12 6LT 01252 350582 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) clare.twomey@new-dimensions.org.uk www.new-support.org.uk New Support Options Limited Miss Clare Twomey Care Home 5 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (1), Physical disability (5) of places DS0000013508.V340673.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The people with supports may have both learning and physical disabilities The age/age range of the persons to be accommodated will be: 40 65 Years of age, with one people with support over the age of 65 years. 8th December 2006 Date of last inspection Brief Description of the Service: 4a Ash Street is a modern bungalow situated just off the main road on the outskirts of Ash Village. Windsor Housing Association owns the premises and the service is provided and managed by a not-for-profit organisation, New Support Options Ltd. Accommodation and personal care is provided for up to five persons, people with support who have both physical and learning disabilities. The four people with support have a single bedroom and there is also an open style kitchen and dining room, lounge area, sensory room and laundry. There is parking available at the front and side of the property. The current weekly fees are from £1,248-13-£1,364.57. DS0000013508.V340673.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit formed part of the key inspection process and took place over three hours fifty minutes commencing at 11.40 and ending at 15.50pm. Mrs V Bulbeck, Regulation Inspector carried out the visit. The individuals living at the home prefer to be called ‘people with support’ and this is how they will be referred to in this report. A full tour of the premises was undertaken. Two care plans were sampled and the care observed for the two people with support. The inspector observed the care provided on the four people with support, the four people with support are unable to communicate. Six members of staff were spoken to during the visit and a number of records were observed. The registered manager Miss Clare Twomey was not available on the day of the visit. The senior support workers were involved in the inspection process. There were four people with support living in the home on the day of the site visit and there was one vacancy. The inspector would like to thank the people with support and staff for their cooperation and hospitality during the inspection. What the service does well: The inspector spoke to the four people with support; all were cheerful and happy they were well dressed and staff are able to ensure. Observations by the inspector that people with supports and staff have a good rapport. There is one person living in the home who is registered blind and arrangements have been made for any documentation to be transferred to a tape, to enable the person to be able to listen instead of staff reading to him. This high lights the person independence. The inspector spoke with six members of staff on duty on the day of inspection; staff commented they feel supported by the management of the home and work as a stable team. The home was homely and welcoming and all areas in the home were clean and personalised. DS0000013508.V340673.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. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000013508.V340673.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection DS0000013508.V340673.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. New admissions to the home are only admitted following a needs assessment to ensure that the home can meet the people with support’s identified needs. The home does not offer intermediate care. EVIDENCE: All people with support entering the home have a pre needs assessment carried out to ensure the home can meet the people with support needs. The staff on duty explained that full details of any potentially new people with support would be undertaken when the person enters the home. The admission procedures and criteria reflect the principles of admission and assessment appropriate to the home. The pre assessment document was seen and it was noted that people with support are involved in the assessment, prior to admission to the home. The staff on duty informed the inspector that a copy of the people with support’s guide is provided to each individual person, this is also provided on a tape. The document is kept in each people with support’s bedroom, relatives are also provided with a copy. This document was checked on this visit and found to be informative and detailed; it is updated on a yearly basis. DS0000013508.V340673.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people with support’s health, personal and social care needs are set out in an individual plan of care, to demonstrate needs are met in accordance with the homes philosophy. People with support are treated in a respectful and sensitive manner. EVIDENCE: Two people with support care plans were sampled and there was evidence that people with support’s health, personal and social care needs had been identified and assessed. Care notes were detailed to include people with supports daily routines. People with support are unable to be involved with their care plan. An action plan is in place to meet the physical care needs of the people with support, to ensure the support, comfort and dignity of the people with support is maintained. The care plans are kept in each persons bedroom, staff have access to the care plans to enable staff to use them as a working tool. DS0000013508.V340673.R01.S.doc Version 5.2 Page 10 Staff stated that people with support are supported to make decisions affecting their lives in a number of ways. Each person with support has an allocated key worker, who is trained to offer one to one support and who knows the person with support well and understands his or her needs. The people with support have limited communication and staff has the experience to enable people with support to make some decisions and choices. Holidays, menu planning and outings are mainly staff interaction and generally knowing the people with support well. Staff advised that information is provided to people with support to assist with decision- making and this is in a format to suit their individual needs. People with support’s care plan should indicate who are unable to hold a key to their bedroom; care plans must be documented to include the reasons for not holding a key. Observation by the inspector was staff are respectful to the people with support. It was also noted that people with support and staff have a good rapport. DS0000013508.V340673.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people with support have opportunities for personal development and to take part in appropriate activities within the home and in the local community. They are supported and enabled to maintain and develop appropriate personal and family relationships. Systems are in place to ensure that people with supports’ rights are respected. EVIDENCE: People with support are supported to make choices in their everyday lives as far as they are able. Families of people with support are consulted and encouraged to be involved in the decision making process. The four people with support attend various activities; some of the activities are in the home. For example, Us in a Bus visit the home on a weekly basis. Aromatherapy is a weekly practice. One person with support attends drama classes on a weekly basis and three persons with support attend an art session once a fortnight. Staff takes people with support shopping and for walks, and meals out to the pub. DS0000013508.V340673.R01.S.doc Version 5.2 Page 12 All four people with support visit the hydrotherapy pool on a weekly basis. Mencap support workers are involved with three people who live in the home; this involves supporting people going out for walks and trips to the coast, particuarly West Wittering. The home has its own vehicle for the people with support. Staff informed the inspector it is difficult at times to use the vehicle with the present staffing levels. Depending on the number of people with support using the vehicle if for example there is only one person using the vehicle and one member of staff who will also drive the vehicle. There must be two members of staff in the home supporting the people with support who remain in the home. However, there is not always a member of staff on duty who is able to drive the home’s vehicle, which causes problems with going out. The four people with support are going on holiday to Selsey, the second week in June 2007. Two people with support will go for the first three days and the other two people with support will go for the second part of the week. The meals observed were nutritional and well balanced. Staff informed the inspector that people with support are involved with the menu planning. The menu is in pictorial form and displayed on the notice board. Staff supports people with support to ensure they eat healthily. Food intake and nutritional content is monitored and all people with support are weighed monthly. A Speech Therapist is involved with two people who has swallowing difficulties, and provides the home with advise on the food intake. The home has a quality assurance system in place to gain feedback from people with support and their families. All members of staff receive training at induction on respecting and promoting the rights of people with support. DS0000013508.V340673.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal care and healthcare support and assistance is planned and was seen in care notes, to be provided, where needed, in a respectful and sensitive manner. EVIDENCE: The inspector was informed by staff that people with support are able to choose when to go to bed and when to get up and are supported to choose their own clothes, hairstyles and other aspects of personal grooming. There are regular visits to the local G.P and people with support have an annual health check. All people with support are constantly observed from the medical team as well as other professional health care people, including the dentist, optician, chiropodist and physiotherapist. The management of the home will liaise with support services to ensure appropriate equipment is received for example, hoists. A number of risk assessments were seen and are reviewed three monthly, several risk assessments were in place for each person with support, and the member of staff explained the process is updated on a regular basis. DS0000013508.V340673.R01.S.doc Version 5.2 Page 14 The system for medication administration was seen and was generally carried out to a high standard. The Medication Administration Record (MAR) sheets were seen and no gaps in the recording were noted. Staff stated key workers, who report in turn to the registered manager, monitor the MAR sheets. Any recurring gaps or errors would be referred to the manager, and this would be discussed with the member of staff. Staff informed the inspector that a member of staff making the entry signs any additional entries to the MAR sheet, which have been handwritten. A member of staff signs the MAR sheet for all medication administered and a second member of staff signs the witness sheet. One member of staff signs the MAR sheet for the receipt of medication into the home, and two members of staff sign the medication stock book after medication has been checked. Sample signatures of all staff that administer medication were held with the MAR sheets for ease of reference. Medication was seen to be well organised and all staff have received training. There are no people who need support who are able to self medicate. DS0000013508.V340673.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All required policies, procedures and practices are in place to ensure that people with support are safeguarded, as far as reasonably possible, from harm or abuse. EVIDENCE: The last recorded complaint was received in 2005 and had been dealt with appropriately. The member of staff informed the inspector there were no external complaints received. Records seen indicated that complaints would be responded to within the guidelines. The homes complaints procedure for people with support is in pictorial form however people with support would not be able to use the procedure unaided. The complaints form is written with widget symbols and easy for people with support to understand and a copy is held in each person with support’s bedroom. All relatives have also been provided with a copy of the complaints procedure. The staff team have completed all mandatory training including vulnerable adults training. Staff spoken to, stated that they had undertaken training in the protection of vulnerable adults and would report any concerns they had to the manager. Staff said they would be willing and able to report any concerns and “would go to any level to protect people with support”. The finances of two people with support were checked and found to be correct and the money balanced against the records held. The receipts were available and matched the records. People with support finances are paid directly into DS0000013508.V340673.R01.S.doc Version 5.2 Page 16 their bank and fees for their placement are paid directly to New Options Limited. The registered manager is responsible and manages any personal allowance money for the people with support; staff are involved in this process. It was noticed that people with support purchase a number of items including bedding and one person had purchased bedroom furniture. The inspector asked a member of staff if this was the usual procedure and was informed it was. Any items of furniture or bedding should be provided by the home unless under special circumstances permission has been obtained either from the care manager or a relative. The information and agreement for this purpose needs to be clearly documented and should be held on the person with support’s file. The inspector will obtain clarification from care management if an agreement has taken place. DS0000013508.V340673.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements in the home need to be continuous in order to ensure a safe and well-maintained environment for people with support. EVIDENCE: The environment is homely and welcoming, all bedrooms were personalised with some items purchased by the people with support. The home was observed to be clean and hygienic on the day of the visit. However, a number of requirements regarding property maintenance are still outstanding from the previous inspection. There are some areas in the home, which are considered to be a health and safety aspect, for example fire doors not closing, and velux windows not opening. Some areas in the home are in need of decoration. The service manager stated that some time during 2007 a number of areas in the home would be decorated. The problem the home is having with regards to any work needing to be undertaken is because the property is owned by the Housing Association and any work required has to be agreed. DS0000013508.V340673.R01.S.doc Version 5.2 Page 18 The garden is accessible to the people with support and clearly the people with support enjoy sitting in the garden when the weather permits. The people with support sit in the garden while staff cut the grass. The garden needs attention; it is currently over grown with weeds around the sides and back. Arrangements are in place for the probation service to be involved with the work required in the garden. In the meantime the garden needs to be cleared of the weeds to enable the people with support to enjoy the garden during the summer months and good weather. DS0000013508.V340673.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staffing levels need to be reviewed to ensure they meet the needs of people with support, to enable the people requiring support are able to make full use of the transport facility. The staff are trained and competent to support the people living in the home. EVIDENCE: The staffing arrangements at present are three support staff on duty during the waking day. The night time arrangements are one waking member of staff and a sleeping in member of staff. The staff undertake a number of domestic duties these include the cleaning, laundry and cooking. The staff also cut the grass in the back garden, on occasions. On the day of the site visit, a member of staff had recently cut the grass in the centre of the garden. However, the garden beds or surrounding areas was very high with weeds. A member of staff informed the inspector that arrangements are in place for a person from the community to undertake the gardening sometime in the near future. Staffing arrangements need to be reviewed to enable staff to DS0000013508.V340673.R01.S.doc Version 5.2 Page 20 undertake these duties, as this would impinge on the time spent with the people with support. Staff records were not available on the day of the site visit. The registered manager holds the key to the filing cabinet where the files are stored and was not on duty. The area manager came to the home but did not have access to the filing cabinet. The staff files must be available for inspection purposes and a responsible person should hold a key when the registered manager is not on duty. The inspector has been informed that arrangement have been made for the area manager to hold the keys to the staff records in the absence of the manager. All staff had completed induction training, staff undertakes Intensive Interaction training, this training is particuarly good for people with support who are unable to communicate. Training records were well documented and a number of courses have been undertaken, certificates were available in the training folder. The member of staff in charge informed the inspector that equality and diversity training is part of the induction training. However, a certificate of attendance was not available. Each member of staff has their own training folder including the training certificates, these folders are maintained by the staff member and are held in the office. The inspector was able to speak with all the staff on duty during the time of the inspection. Staff spoken to confirm they are aware of the different needs of the people with support and have a good understanding and ensure their needs is being met. Interaction between staff and people with support was observed to be good. One member of staff has completed NVQ Level 2, and one member of staff has completed NVQ Level 3. Another member of staff has completed NVQ Level 2 and Level 3. There are currently two members of staff working towards NVQ Level 2 and above. This information was taken from the Annual Quality Assurance Assessment, self assessment (AQAA) received following the inspection. DS0000013508.V340673.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home needs to ensure that the health, safety and welfare of people with support is promoted and protected from harm and abuse, this must include fire safety. EVIDENCE: The service manager informed the inspector a quality assurance audit is undertaken on a regular yearly basis. However, the survey was not available. The monthly monitoring visits by the responsible person were well documented and covered a wide area of care practice in the home. It was disappointing that five of the previous requirements had not been met. A number of these requirements involve the premises, the inspector was informed by the service manager that the housing association who are responsible for the premises, are aware of the problems. The service manager stated that a number of areas in the home are to be decorated this year. DS0000013508.V340673.R01.S.doc Version 5.2 Page 22 The office door was found to be propped open; this was because the heat in the office with the door closed is unbearable to work in. At the time of the site visit the Velux windows could not be opened. A member of staff informed the inspector the home has been informed by the company they are waiting for a part, and the parts required have been discontinued. The laundry door is not closing it was reported on 27/11/06 remains in the same state of disrepair. This is a fire risk. The home operates a number of good practices with regard to health and safety. For example, risk assessments are in place for all people with supports, the hazardous substances cupboard was securely locked, and a member of staff has been given responsibility for overseeing the health and safety of the home. The Commission for Social Care Inspection sent a number of surveys to the home to be completed, these have not been returned to date therefore the report will not contain any information the completed surveys could have provided. The completed AQAA was not received until after the site visit. DS0000013508.V340673.R01.S.doc Version 5.2 Page 23 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 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 N/A 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X X X 3 X X 2 X DS0000013508.V340673.R01.S.doc Version 5.2 Page 24 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 YA24 Regulation 23.(2)(d) Requirement The registered person must ensure that the water damage to a ledge in the bathroom and at the back of the bath is redecorated. (Timescale 08/03/07 not met). Timescale for action 25/07/07 2 YA24 23.(2)(d) 3 YA42 23.(4) (a)(i) 4 YA42 23.(4)(a)(c)(i) The registered person must 25/07/07 ensure that all areas of the home for example doorframes and the window ledge in the laundry are reasonably decorated. (Timescale 08/02/07 not met). The registered person must 25/07/07 take adequate precautions against the risk of fire. The fire doors, which are not closing properly, must receive attention. (Timescale 08/12/06 not met). The registered person must 25/07/07 consult with the fire authority to ensure that adequate arrangements are in place, regarding the office door, for containing fires and if Version 5.2 Page 25 DS0000013508.V340673.R01.S.doc necessary a magnetic holding device must be fixed to the office door. (Timescale 08/01/07 not met). 5 YA42 23.(2)(p) The registered person must ensure that adequate ventilation is provided for the supported people in all parts of the home and the Velux windows in the home, which are not working are repaired. (Timescale 08/03/07 not met). 25/07/07 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 Refer to Standard YA24 YA42 Good Practice Recommendations The garden needs attention. Management to review staffing levels. 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