Inspection on 02/10/07 for Adepta John Paul House 7-9 Pound Lane

This inspection was carried out on 2nd October 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Adepta John Paul House 7-9 Pound... 30/09/09

Adepta John Paul House 7-9 Pound... 02/10/08

Adepta John Paul House 7-9 Pound... 25/05/06

Adepta John Paul House 7-9 Pound... 18/11/05

Adepta John Paul House 7-9 Pound... 13/06/05

Adepta John Paul House 7-9 Pound... 09/12/04

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

CARE HOME ADULTS 18-65 Adepta John Paul House 7-9 Pound Lane John Paul House 7-9 Pound Lane Willesden London NW10 2HS Lead Inspector Andreas Schwarz Key Unannounced Inspection 2nd October 2007 09:30 DS0000062635.V342937.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 DS0000062635.V342937.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. DS0000062635.V342937.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Adepta John Paul House 7-9 Pound Lane Address John Paul House 7-9 Pound Lane Willesden London NW10 2HS 020 8451 6843 020 8343 8876 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) www.pentahact.org.uk Adepta Care Home 8 Category(ies) of Learning disability (8) registration, with number of places DS0000062635.V342937.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th May 2006 Brief Description of the Service: John Paul House is one of a number of care homes formerly managed by Hillstream Care Limited. The organisation merged with Pentahact in September 2004. The home is registered to accommodate 8 adults with learning disabilities. At the time of the inspection there was no vacancy. The weekly fees range from £62.35 to £ 94.45 per week. The property is situated on Pound Lane and there are good links with public transport. There are a number of shops close by. The property is detached and has a large driveway for off street parking. There is a large garden at the rear. The property consists of two floors and on the ground floor there are two bedrooms, a shared toilet and bathroom. There is an office, laundry room, lounge and large kitchen/diner. On the first floor are 6 further bedrooms for residents, bathroom with toilet, another toilet, a storeroom and a staff bedroom. Residents attend local day services and are supported to use community facilities such as leisure centres, parks etc. The home has its own transport DS0000062635.V342937.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection lasted 7 hours. The assistant manager was available throughout this key inspection. I spoke with three people using the service and observed the other people. I have case tracked two people using the service and viewed their care plans and any other relating records. The home returned an Annual Quality Assurance Assessment form within the given timescale. The form however contained very little information about the service. I spoke to three members of staff including the assistant manager. I would like to take this opportunity thanking everybody involved during this key inspection. What the service does well: What has improved since the last inspection? What they could do better: DS0000062635.V342937.R01.S.doc Version 5.2 Page 6 I have made twelve new requirements during this key inspection. Assessments are of good quality but must be signed by the assessor, people using the service and/or their representative. Activity plans are in place but must be updated to meet current needs of people using the service. Staff trained in the administration of medication must provide their signatures and initials. The complaints book must be available at all times and all staff must receive Protection of Vulnerable Adults training. A number of requirements have been made addressing the environment, which must be complied with to provide a safe and comfortable living environment for people using the service. Cleaning materials must be locked away at all times. The newly appointed manager must register with the Commission for Social Care Inspection. 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. DS0000062635.V342937.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 DS0000062635.V342937.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): People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Admissions are not made to the home until a full needs assessment has been undertaken. Prospective individuals are given the opportunity to spend time in the home. EVIDENCE: The home had one admission since the previous key inspection. I viewed a detailed assessment; it was not clear who undertook this assessment, as the assessor, people using the service or their representative, did not sign it. I have also viewed an assessment, which has been undertaken by Brent Social Services. In the persons file I viewed an excellent transition plan, which lasted over six weeks and allowed the new person to get slowly used to the new environment and home. The home has a referral procedure in place, which was previously assessed. DS0000062635.V342937.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): People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The service involves individuals in the planning of care that affects their lifestyle and quality of life. The care plans are person centred and are agreed with the individual. The plan is written in plain language, is easy to understand and looks at all areas of the individual’s life. Each care plan includes a comprehensive risk assessment, which is reviewed regularly. EVIDENCE: I have viewed two care plans during this unannounced key inspection. Both plans were of good standard and have been reviewed. The home is involving day services and people using the service families in the review process. I have also viewed a care plan provided by the funding authority in one of the care plans and information has been used and incorporated in the person centred plan. The home has a key worker system in place, key workers meet regularly with people using the service and a report is provided each month to look at the progress and achievements of the person. One person using the service DS0000062635.V342937.R01.S.doc Version 5.2 Page 10 informed me that he knows about his care plan and said that he can find it in the office. People using the service where able to choose their breakfast during this inspection and one person was asked if he would like to go to the day centre or stay at home. The person chooses to go to the day centre and the home did make separate provisions to accommodate his choice. Finances are dealt with through the head office of Adepta and the responsible individual acts as an appointee for people who are not able to manage their own finances. All people using the service have their own account, which they can access and finances kept in the homes safe are correct and records are of good standard. Both care plan folders included detailed risk assessments, addressing behaviours and epilepsy management. Risk assessments are reviewed during the care plan review process. One person using the service had recently an increase in falls, this has been looked at during the risk assessment process and the risk assessment has been updated. DS0000062635.V342937.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): People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service have the opportunity to develop and maintain important personal and family relationships. The staff team gives help with communication skills. People who use services are involved in meaningful daytime activities of their own choice and according to their individual interests and capability. The meals are balanced and nutritional and cater for the varying cultural and dietary needs of the individuals using the service. EVIDENCE: People using the service access local day services, none of the people living at John Paul House are in paid employment. Staff supports people using the service to access the day centre. One of the people living at John Paul House had a day off from the day centre and the home was providing activities at home and in the community. DS0000062635.V342937.R01.S.doc Version 5.2 Page 12 The home has their own vehicle, which can be used by all people using the service. People using the service contribute for petrol and up keep of the vehicle. Staff informed me that the home has no problems with neighbours. Local facilities such as library, swimming pool and leisure centre, parks are in close proximity of John Paul House. I viewed two separate weekly activity plans one of the plans was out of date and activities recorded have changed. The home must ensure to update and review activity plans regularly. The home records people’s participation in activities. Records showed the home is offering a wide range of activities, i.e. cinema, apple club, pub, dinner out and walk, etc. Records showed that people using the service have families involved in their lives. People using the service have regular visits from family members, and relatives are involved in the care planning process. People using the service visit day centres, Gateway Club, apple club to make and maintain friendships. I observed staff interacting with people using the service professionally and saw them knocking before entering rooms. People using the service preferred form of address is recorded in care plans. An aroma therapist is visiting the home regularly and is providing therapy sessions for three people using the service. People using the service can access all areas in the home. People using the service are encouraged to take part in household chores; this however is depending on their skill and ability. The home has clear rules on smoking, alcohol and drugs in place. The home has a varied menu in place. People with communication difficulties can choose meals by using pictures. The home is offering cultural dishes such as plantain, ackee and salt fish, etc for residents from West Indian origin. The home is offering one cooked meal per day and is providing packed lunch when in the day centre. People’s meal choices are recorded. Mealtimes observed were relaxed and people are encouraged to eat as independent as possible. Unfortunately it is not possible for all people using the service to eat together due to the size of the kitchen and dining table. This has been raised in previous inspections. DS0000062635.V342937.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): People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Personal healthcare needs including specialist health, nursing and dietary requirements are clearly recorded in each resident’s plan. Staff respects people using the service privacy and dignity and are sensitive to changing needs. People who use services have access to healthcare and remedial services. The home has an efficient medication policy supported by procedures and practice guidance, which staff understand and follow. EVIDENCE: I viewed clear and detailed support guidelines for staff supporting people using the service. The guidelines provide clear information about peoples needs and how people using the service prefer support. Staff informed me that the guidelines are reviewed during care plan reviews. People using the service access clinical services provided by Brent Learning Disabilities Partnership. Health assessments have been undertaken and medical appointments have been recorded regularly. DS0000062635.V342937.R01.S.doc Version 5.2 Page 14 I viewed very detailed Epilepsy guidelines and monitoring sheets for one of the people using the service. Staff can administer rectal diazepam and appropriate training is provided. Medical notes are of good standard and I have viewed detailed information of the home supporting people using the service with heath related problems. All people using the service are registered with a General Practitioner. The home has medication policy in place. Two members of staff administer Medication. Medication packed by the dispensing pharmacist in doset boxes. Medication Administration Sheet had no gaps and allergies have been recorded. A separate individual PRN procedure is in place. Staff has received medication training. I noted that there was no signatory list in place; this is required. DS0000062635.V342937.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): People using the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure that meets the National Minimum Standards and Regulations. Some staff has had training around Safeguarding Adults but others have a limited understanding in this important area. This could lead to inconsistent knowledge and practice within the service. EVIDENCE: The homes complaints procedure is available in the service users guide; the complaints procedure was previously assessed as compliant with National Minimum Standards. The Commission for Social Care Inspection has been involved in two complaints since the last inspection, which have all been resolved and investigated appropriately. The assistant manager was not able to locate the complaints book, but told me that she knows about this book. I informed the assistant manager that it is required to have access to the complaints book at all times. The home has a Protection of Vulnerable Adults policy in place and the assistant manager showed me the local Protection of Vulnerable Adults guidelines. Previous Protection of Vulnerable Adults allegations have been resolved and reported according to policies and guidance. Staff spoken to demonstrated good knowledge of how to report allegations of abuse. I noted that not all staff has received Protection of Vulnerable Adults training, which is required. DS0000062635.V342937.R01.S.doc Version 5.2 Page 16 DS0000062635.V342937.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): People using the service experience poor outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home does not have an on-going maintenance programme in place. Essential maintenance is only done when a problem has already arisen. A number of the fixtures and fittings need replacing and some of the décor requires upgrading. Space is inadequate for the physical care of the people using the service and does not allow them to use the room comfortably for all the purposes they wish. The home is generally clean and tidy. EVIDENCE: One person was kind enough to invite me to see her room. The room was nicely decorated and pictures as well as personal ornaments were on display. The assistant manager showed me around the home. The home is clean, but I noticed that the living room and the kitchen could become very cramped if all people using the service and care staff are in. This has been raised previously and the home must find ways to increase the space. The toilet seat on the ground floor toilet is broken and must be repaired. The shower door and tiles DS0000062635.V342937.R01.S.doc Version 5.2 Page 18 in the ground floor shower room is broken and must be repaired. Paper towels and toilet rolls were not available on all toilets, which is required. The carpet in the lounge looks very worn and has tears in some places. The carpet must be replaced. The assistant manager informed me, that the home is planning to fit a new kitchen, but was not able to give me a date for when the work is planned. Paintwork throughout the home looks very worn and is flaky in place, the home must ensure to repaint all communal areas. The home undertook an external Health and Safety audit in September 2007, the auditor made a number of requirements, which should be complied with. The assistant manager showed me this year’s budget on the computer and I noted that the organisation did not allocate any money for Decoration and Maintenance and only £750.00 for renewals. Previous inspections rose that the organisation must have a designated maintenance budget, which is still required. I viewed the homes maintenance book and repair requests have been recorded. The home has a utility room, which has a washing machine and electric dryer. The flooring is easy to clean. The home was clean and free of any offensive odours during this unannounced inspection. The home used to have a cleaner, which has not been replaced since leaving the home and care staff currently undertakes cleaning. I noticed that cleaning materials are in a separate lockable cupboard, which was found to be unlocked during this key inspection. DS0000062635.V342937.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): People using the service experience a good outcome in this area. This judgement has been made using available evidence including a visit to this service. The service ensures that all staff receives relevant training that is focussed on delivering improved outcomes for people using the service. The service puts a high level of importance on training and staff report that they are supported through training to meet the individual needs of people using the service. The service has a good recruitment procedure that clearly defines the process to be followed. Staff recruited confirm that the service was clear about what was involved at all stages and was robust in the following of its procedure. EVIDENCE: The home is providing 3 early, 3 late one waking night and one sleep in staff during each day. Staff informed me that at times they feel overstretched and unable to do administrative tasks. I recommend discussing this with staff and allocating a timeslot for staff to do their administrative tasks. The assistant manager informed me that the home is fully staffed since this months. The home has 13 staff employed. A senior member of staff is available during each shift. Training, annual leave and sickness is covered by permanent relief staff. I observed staff coming in to enable people using the service to participate in chosen activities. Four out of thirteen care staff hold and National Vocational DS0000062635.V342937.R01.S.doc Version 5.2 Page 20 Qualification in Care and four are currently working towards achieving this qualification. Staff information is located centrally, but can be accessed on request. I did not assess any staffing records during this inspection, but I asked the assistant manager to provide me with the disclosure numbers of three staff, to ensure they have a Criminal Records Bureau check. Staff interviewed confirmed of having had an interview and having to provide references, before employment was offered. The organisation is providing a good training programme to staff, all new staff attend the co-operate induction, which includes mandatory training. Staff has training records in the training files including copies of any certificates received. Staff receive a wide range of training, Autism, Challenging Behaviour, SCIP training, Epilepsy, Loss and Bereavement, etc. Staff informed me of having received regular supervisions and annual appraisals, which was confirmed by records viewed. DS0000062635.V342937.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): People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager is working towards being qualified to run the Home. The home has access to professional business and financial advice and has all the necessary insurance cover in place to enable it to fulfil any loss or legal liabilities. The home has a consistent record of meeting relevant health and safety requirements EVIDENCE: The new manager Mrs Dorreta McGregor is not registered with the Commission for Social Care Inspection, which is required. Staff informed me that the new manager is very supportive and listens to concerns and problems staff may have. Following this inspection I spoke to the Operations Manager who DS0000062635.V342937.R01.S.doc Version 5.2 Page 22 informed me that the manager is currently in the process of completing her Registered Managers Award and National Vocational Qualification in Care Level 4. The assistant manager informed me that the Quality Assurance Department of Adepta is in the process of analysing service users surveys. I have viewed the most recent business plan, which focuses on people using the service, staff and the environment. People using the service have regular meetings and records were available for inspection. Fire records viewed are of good standard, fire points are tested weekly, equipment was serviced on 16/02/07 and emergency light is tested monthly. Over the past year the home had three planned fire drills. The Landlords Gas Safety Certificate and Portable Appliances Test Certificate is up to date. The home has a detailed Health and Safety manual in place weekly Health and Safety checks are undertaken. DS0000062635.V342937.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 2 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 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 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 3 X DS0000062635.V342937.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 YA2 Regulation 14 Requirement Assessments have to be signed by the assessor, person using the service and/or their representative. Activity plans and other records relating to people using the service must be reviewed and updated regularly. The home must have a list with signatures and initials of staff competent in the administration of medication. The manager must ensure that staff has access to the complaints book at all times, to record any complaints received. All staff must receive Protection of Vulnerable Adults training. The registered person should reconsider the adequacy of the communal space provided for people using the service. This includes sitting areas and dining areas. Timescale for action 01/11/07 2. YA13 17(2) 15/11/07 3. YA20 13(2) 01/11/07 4. YA22 22 01/11/07 5. 6. YA23 YA24 13(6) 23(2)(g) 15/11/07 01/12/07 DS0000062635.V342937.R01.S.doc Version 5.2 Page 25 (Previous timescale of 15/12/05 & 20/09/06 not met) 7. YA24 23(2)(b) The registered person must have a planned maintenance and renewal programme and budget for the fabric and decoration of the premises. (Previous Timescale of 20/09/06 not met) 8. YA24 23(2)(a) The registered person must ensure that the requirements from the Environmental Health officer relating to an asbestos survey, update of light fittings in corridors, extensive refurbishment is complied with. (Previous Timescale of 21/10/06 not met) 9. YA24 23(2)(c) The broken toilet seat on the ground floor toilet must be repaired to enable people using the service using the toilet safely. The shower door and tiles in the ground floor shower room fell off, which could lead to people using the service injuring themselves and must therefore being repaired. The manager and staff must ensure that toilet rolls and paper towels are available throughout the home. 01/11/07 01/12/07 01/12/07 10. YA24 23(2)(b) 01/11/07 11. YA24 13(4)(c) 01/11/07 12. YA24 23(2)(d) Carpets throughout the home 01/12/07 must be replaced to create and safe and comfortable environment for people to live in. The home must redecorate the DS0000062635.V342937.R01.S.doc 13. YA24 23(2)(d) 01/12/07 Page 26 Version 5.2 paintwork throughout the home to ensure people live in a clean and nicely decorated home. 14. YA30 13(4)(a) The manager must ensure that cleaning materials are locked away at all times to minimise the risk of people using the service harming themselves. The newly appointed manager must register with the Commission for Social Care Inspection. 01/11/07 15. YA37 8&9 01/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA24 Good Practice Recommendations The registered person should consider the installation of double-glazing on windows to moderate traffic noise and offer a more conducive sleeping environment for people using the service. Recommendations made during the independent Health and Safety audit in September 2007 should be complied with to increase the quality of life for people using the service. I recommend to provide allocated time for administrative tasks, to allow staff to care planning, key worker reports, etc. 2. YA24 3. 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