Inspection on 15/08/06 for 87 Pinkneys Road

This inspection was carried out on 15th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

87 Pinkneys Road 15/07/08

87 Pinkneys Road 03/11/05

87 Pinkneys Road 01/11/04

87 Pinkneys Road 20/04/04

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Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

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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 87 Pinkneys Road Pinkneys Green Maidenhead Berkshire SL6 5DT Lead Inspector Mrs Rhian Williams-Flew Unannounced Inspection 15 August 2006 10:25 th 87 Pinkneys Road DS0000011274.V307382.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 87 Pinkneys Road DS0000011274.V307382.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. 87 Pinkneys Road DS0000011274.V307382.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 87 Pinkneys Road Address Pinkneys Green Maidenhead Berkshire SL6 5DT 01628 626167 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) londonroad@tiscali.co.uk Milbury Care Services Limited Ms Annie McDermott Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 87 Pinkneys Road DS0000011274.V307382.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd November 2005 Brief Description of the Service: 87 Pinkneys Road is a residential home offering twenty-four hour care. The home is registered for three residents with learning and associated physical difficulties. The residents have been living in the home for several years. Milbury Care Services Ltd provides the service. The house is a bungalow with three bedrooms; all of the bedrooms are single and none of them have en-suite facilities. There is one communal toilet and one communal bathroom and there are a variety of aids and adaptations around the building. The home has its own transport as the local public transport system is limited and it would be difficult for the residents’ to access. The range of fees for the service provided at this home is £1300 - £1450. Additional charges are made for hairdressing services; massage therapy; toiletries and holidays. This information was provided at the time of the site visit. The Registered Manager has confirmed that the most current inspection report is available in the home for viewing. 87 Pinkneys Road DS0000011274.V307382.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The accumulated evidence used to inform this report includes a pre-inspection questionnaire completed on behalf of the Registered Manager of the home; our inspection records held at the local office of CSCI; an unannounced site visit on 15 August 2006. The site visit took place between 10.25am and 6.30pm and was conducted by one Inspector. During the unannounced site visit conversations were held with the members of staff on duty; observations were made of the delivery of care; a tour of the home was made; all case files were case tracked and some records concerning the management of the home were reviewed. The Registered Manager was present for the majority of the site visit. It was not possible to seek the views of the service users as they are unable to converse in verbal conversation. Observations of their interactions with members of staff throughout the visit clearly demonstrated that they are able to make their wishes known through non-verbal communication. What the service does well: What has improved since the last inspection? Additional equipment has been provided for the service users. These include a new bathing system; new wheelchairs and new beds. A fully adapted vehicle has also been provided which allows for all the service users to use it without having to transfer to seating within the bus as it will accommodate them in their wheelchairs. 87 Pinkneys Road DS0000011274.V307382.R01.S.doc Version 5.2 Page 6 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. 87 Pinkneys Road DS0000011274.V307382.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 87 Pinkneys Road DS0000011274.V307382.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. New service users can be assured that their needs would be fully assessed before they were offered the opportunity to live in this home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: This service has not had any new service users since it opened. Therefore assessing whether prospective service users needs and aspirations are assessed before admission has been conducted through the review of the procedures. That is, the Registered Manager would ensure that all prospective new service users had been assessed by the care management procedures of the local authority and she had conducted her own assessment of the persons needs to ensure that the home could meet their needs. 87 Pinkneys Road DS0000011274.V307382.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. Each service user has a clear care plan identifying how their needs are to be met and any risks involved in delivering this care have been assessed. This judgement has been made using the available evidence including a visit to this service. EVIDENCE: The care plans of the three service users were case tracked. The Registered Manager has nearly completed a full review of the care plans. The information contained within them was therefore up-to-date. The plans clearly detail the service users preferences and how their care is to be provided. The plans reflect all aspects of the service users needs and lifestyles and where appropriate the views and involvement of relatives and carers are included. The three service users are unable to express their wishes in spoken language. It is therefore imperative that information about how they communicate their needs and how these are to be interpreted is recorded in their care plans. In all three care plans such details were found. In discussions with members of staff it was clear that they had a very good understanding of how to interpret 87 Pinkneys Road DS0000011274.V307382.R01.S.doc Version 5.2 Page 10 the needs and wishes of the service users through their individual ways of communicating. All of the members of staff spoken with demonstrated their knowledge of each service users individual preferences. Through observation of the interactions between members of staff and service users it was very evident that the members of staff knew immediately on how best to support each service user. None of the service users are able to act as their own advocates with regard to their finances however, all are subject to the provisions of the Court of Protection to safeguard them. All of the service users have clear risk assessments in place within their care plans. These risk assessment allow them to participate as fully as possible in activities within the limitations of their disabilities. 87 Pinkneys Road DS0000011274.V307382.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. Service users fully participate in therapeutic activities at a day centre and in their local community to enjoy leisure activities. Their daily routines are very individual and flexible. The use of less processed food should be considered in the menu choices. This judgement has been made using available evidence including a visit to the service. EVIDENCE: All of the service users participate in therapeutic activities at a local Day Centre. They attend at various times during the week and participate in activities. Some of these activities are passive but are inclusive of the service users. For example, observing cookery and gardening events. The home has access to a fully adapted minibus, which allows for all of the service users to participate in community activities. They use local facilities in their community most days. For example, visits to the shopping areas, library, leisure centre, lunch clubs and local open spaces. The home is situated in a 87 Pinkneys Road DS0000011274.V307382.R01.S.doc Version 5.2 Page 12 residential road of Maidenhead and the Registered Manager reported good neighbourly relations. Not all of the service users have family members. Those that do, are included in the care of their relative. All of the service users have their own spacious bedroom where they could meet their visitors in private. From the care plans and discussions with members of staff it could be evidenced that the service users daily routines are very individual. Their preferences are clearly noted and through observation during the visit it was clear that members of staff respected each service users preference. The menu choices were reviewed prior to the site visit as the information had been provided in a pre-inspection questionnaire. It was noted that a significant amount of meals provided for the service users are pre-prepared processed foods. This issue was discussed with the Registered Manager. She acknowledged that the menus did not fully represent a nutritious and varied diet. It is to be recommended that the Registered Manager review the menu choices to include less processed foods. 87 Pinkneys Road DS0000011274.V307382.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is excellent. The provision of personal and health care support for the service users in this home is of a high standard. Specialist advice is sought to ensure the best outcomes are achieved for the service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans seen for the service users clearly detailed how their personal care was to be provided. It was detailed and specific to the individual needs of the person. Individual preferences with regard to times for waking and retiring to bed were clearly documented. In discussions with members of staff it was very evident that they knew exactly how each service user preferred their personal care to be provided. As all of the service users have specific physical disability needs the members of staff require aids and equipment to assist them in providing personal care. In discussion with the Registered Manager she confirmed that the home had sufficient equipment. It was also evidenced that each service user has received the additional support and advice of physiotherapists and occupational therapists with regard to any equipment they require. 87 Pinkneys Road DS0000011274.V307382.R01.S.doc Version 5.2 Page 14 All of the service users are registered with a local general practitioner. Each service user has access to a care manager and via this provision other professionals are called upon to provide advice, guidance, support and equipment as and when required. There was evidence in the care plans to show that physiotherapists, occupational therapists, behavioural specialists, psychiatrists, chiropodists, dentists, opticians and community nurses have attended to the service users as and when it was required. The home has a clear policy and procedure with regard to the storage and administration of medication. The administration of medicines was observed at lunchtime. The member of staff administering the medication had a good knowledge of the procedures. Care staff are not permitted to administer medication until they have received training and been accredited by the Registered Manager. 87 Pinkneys Road DS0000011274.V307382.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 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 good. The members of staff in the home have received training in the protection of vulnerable adults and the home has procedures in place for whistle blowing and protecting service users from abuse. The home also has a robust complaints procedure. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the previous inspection there have been two complaints received at the service. Both have been resolved to the satisfaction of the complainants. The method of recording the complaints is clear and the audit trail as to their conclusion can be evidenced. The pre-inspection questionnaire included the training achievements of all members of staff. From this document it can be evidenced that the majority of the members of staff have received training in the protection of vulnerable adults. In discussions with members of staff they were able to demonstrate their awareness of whistle blowing procedures and vulnerable adults procedures. 87 Pinkneys Road DS0000011274.V307382.R01.S.doc Version 5.2 Page 16 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. The environment of this home is homely and comfortable. Service users have their own rooms, which are spacious. The home has good levels of equipment to meet the increasing physical needs of the service users. Deficits in the provision of communal space need to be reviewed because of the increasing physical needs of the service users. The external decoration to the home should be improved to ensure that the fabric of the home remains sound. Ensuring that attention to is given to the provision of a dropped kerb so that the minibus for service users use can enter and exit the driveway safely and without discomfort to the service users. Repairs to the fabric of the building should occur promptly to ensure the health and safety of the service users and members of staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The homes premises are homely and comfortable. All of the service users require manual handling procedures to move around the home. All three of the service users have wheelchairs designed for them. Access to and from their rooms to bathing facilities and communal areas is possible as their rooms are all on the ground floor of the property. 87 Pinkneys Road DS0000011274.V307382.R01.S.doc Version 5.2 Page 17 During the review of the fire safety procedures for the home it was evidenced that risk assessments have been completed identifying that the service users should not be evacuated from the premises but contained within the home using fire precautions that are in place until the arrival of the Fire Service. During a tour of the home it was noted that the bedroom door of one service user was not closing properly thus compromising these fire procedures. In addition, the fire door to the staff office was in need of repair to ensure its fire safety. The Registered Manager was able to evidence that she had made requests to the maintenance department some 10 days prior to the site visit. At the request of the Inspector she expedited this maintenance request during the inspection and has subsequently written to confirm that both doors were repaired within 24 hours of the site visit. The facilities in the communal areas consist of a small lounge with a dining room table placed in it. The service users have always lived in this home but as the years have progressed their dependency levels have increased. They require interventions to assist their movement around the home that is, mobile hoists and wheelchairs. The Registered Manager acknowledges that to use this equipment within the existing small lounge is proving to be more problematic for the members of staff who care for the service users. Indeed, if all three of the service users are in the lounge area together there is very little space for members of staff to move around the room. This could present health and safety hazards for the members of staff and ultimately the service users. The Registered Manager commented that the provider, Milbury Care Services Limited, has been considering various options as to how this issue can be resolved. One alternative is to consider extending this room. The bathing facilities within the home have been altered to meet the increasing needs of the service users. An “Easibath” with a shower adapter has been installed and comments from members of staff confirmed that they find it ideal for all the service users. It also assists them with regard to their health and safety requirements. The internal decorations of the home are maintained and appropriate to the service user group who live in the home. The external decorations of the home are in need of attention as the paintwork to windows and doors is peeling or has already fallen away leaving exposed woodwork. Attention needs to be directed to this area of refurbishment, as the fabric of the building will deteriorate without action being taken. The home was noted to be clean and hygienic and free from odours. The laundry facilities are sited on the first floor and there are clear procedures in place to ensure the safe hygiene procedures are followed with regard to the completion of laundry. 87 Pinkneys Road DS0000011274.V307382.R01.S.doc Version 5.2 Page 18 There are two driveways to the premises one is specifically used for an adapted minibus that service users require in order to access community facilities. It was noted that the kerb in the public footpath has not been lowered to accommodate access to the driveway. Therefore, members of staff are having to drive the bus over the normal height kerbstone. Bearing in mind that all the service users who will be travelling in this bus are secured in their wheelchairs, travel over such a kerbstone height could compromise their health and safety as well as their comfort. The Registered Manager was able to demonstrate that she has made several requests for this to be attended but nothing has been forthcoming. Subsequent to the inspection she has written to confirm that the companys surveyor in conjunction with the local council is addressing the issue. Resolution of this matter must be a priority. 87 Pinkneys Road DS0000011274.V307382.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 Quality in this outcome area is good. The home does have a full compliment of staff that does access regular training and are supervised. The home also has robust recruitment procedures. The exception to this outcome is that on the day of the site visit the service users were being cared for by one member of staff for a period of time. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The completed inspection questionnaire and confirmation by the Registered Manager advised that the home is fully staffed. The Registered Manager confirmed that because of the needs of the service users within the home there should always be two care staff on duty throughout the waking day and one member of night staff. Indeed, the Registered Manager commented that members of staff have recently suggested that 3 members of staff should be available during the morning period to ensure that all the service users needs can be met in a timely way, to ensure they can attend their daytime activities. The Registered Manager confirmed that she intends to have discussions with her senior managers with regard to this provision being considered. As the site visit commenced only one member of staff was present in the home with the three service users. The Inspector was advised that the other 87 Pinkneys Road DS0000011274.V307382.R01.S.doc Version 5.2 Page 20 member of staff had gone to complete shopping tasks and the Registered Manager was not expected until later in the morning. The presence of one member of staff in the home with all of the service users was clearly in contravention of the homes own staffing requirement. When reviewing the care being delivered to the service users by the one member of staff it was noted that they were all bathed and dressed and in appropriate seating to ensure their comfort. When the Registered Manager arrived at the service she was advised of the staffing arrangements, which she accepted were inappropriate to meet the needs of the service users in the home. She also confirmed that this practice did not routinely occur. The pre-inspection questionnaire confirms that members of staff are receiving appropriate training to meet the needs of the service users. Four members of care staff have achieved NVQ qualifications. The recruitment procedures in the home were reviewed with the Registered Manager and were noted to be thorough and ensure that service users are supported and protected by robust recruitment procedures. Supervision of staff occurs on a regular basis. 87 Pinkneys Road DS0000011274.V307382.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. The Registered Manager is qualified and competent to manage the home and receives support from her senior members of staff to manage the home. The home has good quality assurance systems in place, which assist in the review and development of the service to meet the ongoing needs of the service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager is qualified and experienced to run the home. The Manager is also registered for another service in a nearby street run by the same provider, Milbury Care Services Ltd. She works full-time hours, shared between the two homes. Support from her senior staff is therefore required to ensure the effective running of the home. The Registered Manager has ensured that there are quality assurance systems in place to monitor the provision of service within the home. Random samples 87 Pinkneys Road DS0000011274.V307382.R01.S.doc Version 5.2 Page 22 of these documents were reviewed during the site visit and were noted to be up-to-date and relevant. Appropriate actions were noted to have been taken where deficits had been identified. A review of the Responsible Individuals monthly visits to the premises demonstrated that audit systems within the management of the service are in place. The training records provided with the pre-inspection questionnaire demonstrated that members of staff are receiving mandatory health and safety training to ensure the well-being of themselves and service users. The preinspection questionnaire also detailed information regarding compliance with other regulatory bodies and authorities and regular servicing of equipment does occur. 87 Pinkneys Road DS0000011274.V307382.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 2 34 3 35 3 36 3 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 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 3 X 3 X X 3 X 87 Pinkneys Road DS0000011274.V307382.R01.S.doc Version 5.2 Page 24 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 Requirement Timescale for action 31/03/07 2 YA24 3 YA24 4 YA24 23(2)(a)&(f) The Responsible Individual must review the provision of additional communal space with the Registered Manager in order to meet the increasing needs of the service users. If it is assessed that additional space is required then the Responsible Individual will need to develop an action plan as to how this is to be achieved and in what timescale. 23(2)(b) The Responsible Individual 30/11/06 must take action to ensure the external decoration of the home is refurbished. 23(2)(b) The Responsible Individual and 31/08/06 the Registered Manager must ensure that maintenance of the home is completed promptly particularly if health and safety matter are compromised. For example, fire doors etc 23(2)(o) The Responsible Individual and 31/10/06 the Registered Manager must ensure a solution to the provision of a dropped kerbstone to ensure the safe travel of the adapted minibus whilst it is entering and exiting DS0000011274.V307382.R01.S.doc Version 5.2 87 Pinkneys Road Page 25 the property. 5 YA33 18(1)(a) The Registered Manager must 31/08/06 ensure that there are, sufficient staff on duty at all times to care for the service users. 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 YA17 YA33 Good Practice Recommendations The Registered Manager to review the menu selections to ensure that the service users are offered less pre-prepared meals and more freshly prepared meals. The Registered Manager to conduct the review of the deployment of staff with her senior managers. This is as a direct result of staff feedback. 87 Pinkneys Road DS0000011274.V307382.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA 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 87 Pinkneys Road DS0000011274.V307382.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!