Inspection on 25/05/06 for Adepta John Paul House 7-9 Pound Lane

This inspection was carried out on 25th May 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 8 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... 02/10/07

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 Pentahact JP House 7-9 Pound Lane John Paul House 7-9 Pound Lane Willesden London NW10 2HS Lead Inspector Dia Balraj Key Unannounced Inspection 25th May 2006 10:00 Pentahact JP House 7-9 Pound Lane DS0000062635.V294780.R01.S.doc Version 5.1 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 Pentahact JP House 7-9 Pound Lane DS0000062635.V294780.R01.S.doc Version 5.1 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. Pentahact JP House 7-9 Pound Lane DS0000062635.V294780.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Pentahact JP 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 PentaHact Lorenzo Domech Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Pentahact JP House 7-9 Pound Lane DS0000062635.V294780.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 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 one 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 Pentahact JP House 7-9 Pound Lane DS0000062635.V294780.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on the 25th May 2006 and started at 08:15 in the morning and lasted 8 hours. There were three staff on duty assisting seven service users. The Inspector was able to observe the early morning routine including the serving of breakfast. However, five of the service users left after breakfast to attend day care. The residents have a range of learning disabilities and some have challenging behaviours. The majority have little or no verbal communication skills. The inspector viewed documentation for the service users and the home. She talked with the manager, the staff and observed the interaction between staff and service users. She spoke at length with one of the service users who talked about his time at the home and how he was looked after. The inspector toured the building. The inspector convened a meeting with the care manager on the 4th July for an update on the urgent issues, which were discussed during this inspection. The findings are reflected in this report. What the service does well: What has improved since the last inspection? The home has implemented most of the requirements including those, which were made after this inspection. The Care manager updated the inspector after this inspection on the implementation of the fire officer’s and Environmental health officer’s requirements. The first floor landing door is now effectively self- closing. Staff have had fire safety training and risk assessments from identified fire hazards have been completed. A fire risk assessment as advised on this visit has been completed. Pentahact JP House 7-9 Pound Lane DS0000062635.V294780.R01.S.doc Version 5.1 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. Pentahact JP House 7-9 Pound Lane DS0000062635.V294780.R01.S.doc Version 5.1 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 Pentahact JP House 7-9 Pound Lane DS0000062635.V294780.R01.S.doc Version 5.1 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 was good. This judgement has been made using evidence available on the site visit. A thorough assessment of residents’ needs is carried out to ensure that their needs are met. EVIDENCE: The inspector obtained evidence from documentation, from observation and from discussion with the manager. The documentation of the last admission was examined and included a Care Management assessment plan. There was also evidence of care assessments by the Manager. The manager stated that the resident concerned had undertaken visits to the home. The resident was introduced to other residents and had meals at the home to gauge how well she fitted in with the group. The documentation examined confirmed that the prospective service user was able to experience the home environment before making the decision to accepting placement. Further visits were arranged as a means of gradually integrating the resident. The family was also invited to the home during this period. The care plans examined identified residents’ needs and the proposed action to achieve objectives. Pentahact JP House 7-9 Pound Lane DS0000062635.V294780.R01.S.doc Version 5.1 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 was good. This judgement has been made using evidence available on the site visit. Residents’ needs are identified and theyare enabled to make choices. EVIDENCE: Evidence was obtained from observation of care, from speaking to a service user and his key worker and from documentation. Care plans clearly identified objectives with service user’s participation. The recommendations set at review meetings stated the resources required, the person responsible for monitoring progress. The changing needs of service users were addressed. A service user has had an OT assessment and has been referred to the Health team for advice and support. The inspector observed the use of systems of pictorial communication some of which were displayed in the kitchen/dining room. Service users are supported to make decisions about their lives. The inspector viewed the documentation of the use of pictorial communication between the service user and key worker at monthly reviews. The activities are set out in pictorial form enabling service users to exercise choice in activities. These include visiting friends, eating out, arts and crafts, walking, music, reflexology and aromatherapy and swimming. Pentahact JP House 7-9 Pound Lane DS0000062635.V294780.R01.S.doc Version 5.1 Page 10 Most residents have contact with family or advocates. Residents’ independence is encouraged. They are involved in going to the bank and sign their cheques. Residents also have the freedom of going in and out of the kitchen at any time, The residents partake their meals and have drinks in the kitchen/diner. The inspector advised that a risk assessment of the use of the kitchen be carried out to ensure residents’ safety at all times. The manager has since implemented a risk assessment aimed at minimising risks to potential hazards. Pentahact JP House 7-9 Pound Lane DS0000062635.V294780.R01.S.doc Version 5.1 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 and 17 Quality in this outcome area was good. This judgement has been made using evidence available on the site visit. Service users are enabled to undertake activities in the home and in the local community. Their rights are respected and they are offered a healthy diet. EVIDENCE: The current service users all attend day care five, four and 3 days a week. They are engaged in a number of activities including cooking sessions. During the inspection the inspector observed one service user making the choice not to attend day care. Staff supported this decision. One day a week the service users choose activities that are supervised by the home staff. Activities are chosen from a range of activities that are presented in pictorial form and displayed in the entry hall. The home has a car and service users are able to go shopping or to parks. The home has recently acquired a 7-seated Transporter to allow all service users the opportunity of outings at the same time. The home has an equal opportunities policy. The team is multicultural and have a good understanding of service users’ cultural backgrounds. The Pentahact JP House 7-9 Pound Lane DS0000062635.V294780.R01.S.doc Version 5.1 Page 12 inspector noted from speaking with a resident that he had a choice of key worker. Service users are encouraged to participate in community activities. They go out to the pub, swimming, eat out, clubs, swimming. They have a holiday abroad once a year. Service users have the opportunity to go on holidays of their choice. The service user who spoke with the inspector explained that he had been to the Canary Islands, Devon and Butlins. Staff acknowledge the service users’ rights to independence and privacy within the home. The manager was seen to knock on the bedroom doors before entering and the inspector noted that the service users were spoken to with dignity and respect. The inspector noted that staff were attentive when service users communicated with them. All bedrooms have an individual key to allow the service user the opportunity to lock their doors. Meals are offered three times a day with snacks in between. This is at the discretion of the service users. The menu is prepared from service users’ choices expressed at residents’ meetings. These included pasta, fried rice, fish, pizza and cultural meals. Family are encouraged to maintain contact with the service users. Some of the service users go home on weekends and occasionally family visit the home. The home utilises an independent advocate for those who do not have family involvement. The service users also visit the residents at other learning disability homes. A barbecue was being organised combining residents from three homes Pentahact JP House 7-9 Pound Lane DS0000062635.V294780.R01.S.doc Version 5.1 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 and 20 Quality in this outcome area was good. This judgement has been made using evidence available on the site visit. Service users receive appropriate personal support. The health care needs of service users are met. Service users are protected by the home’s medication policy. EVIDENCE: Service users’ assistance with personal care is identified in their individual plans. On the day of inspection it was observed that sensitive care was provided i.e help with shaving. The team is multicultural and staff interviews confirmed that they have a good understanding of service users’ cultural backgrounds. The inspector noted from speaking with a resident that he had a choice of key worker. Service users are registered with the local GP and can make appointments as and when required. They are also enabled to access health care facilities such as Psychiatrist, epilepsy nurses, chiropodist, optician, dentist. Documentation suggested that regular reviews were being carried out. The home has a medication procedure. None of the service users self medicate. The MAR sheets of two residents chosen at random confirmed that the administration of medication was in order. All medication had dates of review. All permanent members of staff had followed medication training. The home ensures that only trained staff have responsibility for the administration of medication.. Pentahact JP House 7-9 Pound Lane DS0000062635.V294780.R01.S.doc Version 5.1 Page 14 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 and 23 Quality in this outcome area was good. This judgement has been made using evidence available on the site visit. The complaints’ procedure ensures that service users views are acted upon. The POVA policy contributes to service users being protected from abuse. EVIDENCE: The home has a complaints policy in place. The documentation reviewed confirmed that complaints were adequately dealt with. The resident interviewed stated that he felt confident in approaching staff with any problem and they would try and resolve it. The complaints procedure was displayed on the notice board and in the reception area. The home had a POVA policy and the staff interviewed had knowledge of the policy including the Public Disclosure Act 1998. Staff had followed POVA training and had knowledge of the policy for dealing with Aggressive behaviour and of crisis intervention strategies. The home had a copy of the London Borough of Brent POVA policy to ensure that appropriate procedures are followed if required. Records of the personal allowance of two residents were checked and were in order. Pentahact JP House 7-9 Pound Lane DS0000062635.V294780.R01.S.doc Version 5.1 Page 15 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, 27, 28 and 30 Quality in this outcome area was adequate. This judgement has been made using evidence available on the site visit. Service users live in a homely environment, but changes to the existing environment are required to ensure the welfare of service users. The home is clean and hygienic. EVIDENCE: The inspector was invited by a resident to see his bedroom. He stated that he was pleased with his room. The room was light and airy The décor was matching and there was plenty of storage place. Some of the rooms are carpeted while 2 others have lino on the floor. Service users should be given the option of having suitable flooring to suit their needs and lifestyles. Service users have the option of staying in their bedrooms when they wish. The inspector noted that all of the bedroom doors had a lock so that service users have the opportunity to maintain their privacy and independence. During the inspection one of the service users was seen to lock his bedroom door while he was in his room. Pentahact JP House 7-9 Pound Lane DS0000062635.V294780.R01.S.doc Version 5.1 Page 16 The communal areas are well decorated but the communal space is not adequate. Service users need to be provided with additional seating areas to accommodate the large number of service users and staff or for when a service user displays challenging behaviour. There is a communal television although there is also provision for the service user to have their own televisions in their own rooms. The home is decorated with domestic furniture. A number of cracks were observed throughout the property. The ground floor bathroom required redecoration and the walking shower, a requirement from the last inspection to meet the needs of a resident had not been installed on the day of this inspection. The walking shower was installed on the 20th July 2006. The exterior casing of the first floor bath had a splint protruding and presented a safety risk to any one using the bathroom. The inspector required that the bath be made safe as a matter of urgency and that the splint be blocked as a temporary measure to ensure service users’ safety. The inspector received confirmation that the exposed split had been sealed as a temporary measure. It is required that the bath be repaired or replaced. It was also noted during the inspection that double-glazing did not moderate the traffic noise from the main road. The inspector spoke with the manager who agreed that some of the service users did have difficulty sleeping and that noise could be a factor. The home did not have a planned maintenance and renewal programme for the fabric and decoration of the premises. This is a requirement to ensure the safety and welfare of residents at all times. During the inspection the home was seen to be clean and hygienic. A cleaner is employed 10 hours a week. Staff are allocated a number of hours to attend to domestic duties. Pentahact JP House 7-9 Pound Lane DS0000062635.V294780.R01.S.doc Version 5.1 Page 17 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 and 35 Quality in this outcome area was good. This judgement has been made using evidence available on the site visit. Service users are supported by competent and qualified staff. EVIDENCE: The evidence was based on observation of interaction between staff and service users, feedback from a service user and interview with the manager and staff. Staff showed respect for service users and addressed them politely. Staff were observed attending to service users’ needs for example by helping them to serve their breakfast. The establishment consists of a Manager, Deputy, 2 senior support workers and 6 support workers. The inspector interviewed the manager, the deputy and 3 support workers. They demonstrated knowledge of the specific needs of residents and a knowledge of their cultural and religious backgrounds. The establishment has a staff training and development programme. 5 staff hold the NVQ level 2 and have followed training including: Makaton, Food Handling, Diabetes, Dysphagia, Medication, epilepsy, Fire safety, Moving and Handling. The home has a recruitment policy which is based on equal opportunities and checks ensure the protection of service users. Pentahact JP House 7-9 Pound Lane DS0000062635.V294780.R01.S.doc Version 5.1 Page 18 The home’s recruitment policy states that applicants must pass a CRB and POVA and POCA checks before being employed. They must also have 2 satisfactory current references and show that they are eligible to work in the UK. Staff’s files were not available for inspection. All staff files must be stored at the home so that they are available for inspection at any time. Staff receive formal supervision every two months with the manager or the deputy manager. The yearly appraisal identifies areas for development and it was noted that staff undertook for example training in challenging behaviour as identified in appraisal. Staff have undertaken training in equal opportunities including learning disability training. Pentahact JP House 7-9 Pound Lane DS0000062635.V294780.R01.S.doc Version 5.1 Page 19 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 was good. This judgement has been made using evidence available on the site visit. Service users benefit from a well run home. Service users are confident their views underpin all self-monitoring, review and development by the home. The health, safety and welfare of service users are promoted and protected. EVIDENCE: The manager of the home has experience as a support worker, residential social worker and managing a home for unaccompanied minors. He has completed NVQ training level 4 and is to register for the Registered Managers’ course. He has been managing the home for the last three years. The manager undertakes periodic training. Recent training includes: managing performance, sickness and absence and infection control. The home has a quality assurance procedure where feedback is sought from service users. The service user who was interviewed by the inspector stated that he felt that his aspirations were listened to and acted on Risk assessments on activities of daily living were available. Pentahact JP House 7-9 Pound Lane DS0000062635.V294780.R01.S.doc Version 5.1 Page 20 Residents also have the freedom of going in and out of the kitchen at any time, The residents partake their meals and have drinks in the kitchen/diner. The inspector advised that a risk assessment of the use of the kitchen be carried out to ensure residents’ safety at all times. The manager has since implemented a risk assessment aimed at minimising risks to potential hazards. The manager informed the inspector that the ethos of the home was person centred and the promotion of independence. During the inspection it was noted that service users were supported to make their own choices. A service user was enabled to decide whether to attend or not attend day care. The manager explained that the staff showed their sensitivity to the service user by listening to their needs and acting upon them. The service user who was interviewed by the inspector supported this claim. He informed the inspector that he felt that his aspirations were listened to and acted on. Service user likes and dislikes are documented. On the day of inspection the manager stated that the fire requirement arising from the fire officer’s visit of the 13th April 2006 relating to the corridor door had been reported to Network Housing. The inspector required that this be attended urgently to ensure the safety of residents. The manager confirmed that the work was carried out in early July 2006.onThe Electrical wiring check was in order. Pentahact JP House 7-9 Pound Lane DS0000062635.V294780.R01.S.doc Version 5.1 Page 21 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 2 26 X 27 2 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 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 3 X 3 X X 3 X Pentahact JP House 7-9 Pound Lane DS0000062635.V294780.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA28 Regulation 23(2) g Requirement The registered person should reconsider the adequacy of the communal space provided for service users. This includes sitting areas and dining areas. (Previous timescale of 15/12/05 not met) The cracks throughout the property must be investigated and remedied. Service users should be given the option of having suitable flooring to suit their needs and lifestyles. The registered person is required to ensure that the first floor bath is repaired or replaced. The registered person should consider the installation of double-glazing on windows to moderate traffic noise and offer a more conducive sleeping environment for service users. The registered person must have a planned maintenance and renewal programme for the fabric and decoration of the premises. The registered person must ensure that the requirements DS0000062635.V294780.R01.S.doc Timescale for action 20/09/06 2. 3. YA24 YA25 23(2)b 23(2)f 20/09/06 31/10/06 4. 5 YA27 YA24 23(2) c 20/08/06 31/10/06 23 (2) a 6 YA24 23(2) b 20/09/06 7 YA24 23(2)a 21/10/06 Pentahact JP House 7-9 Pound Lane Version 5.1 Page 23 9. YA34 Sch 4(6) from the Environmental Health officer relating to an asbestos survey, update of light fittings in corridors, extensive refurbishment are complied with. The registered person must 20/09/06 ensure (a) that information on staff as per Schedule 4.6 is made available for inspection. (b) that CRB information is made available for inspection. (Not assessed ) (Previous timescale of 15/12/05 not met) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Pentahact JP House 7-9 Pound Lane DS0000062635.V294780.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 Pentahact JP House 7-9 Pound Lane DS0000062635.V294780.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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