Inspection on 23/06/06 for Apna House

This inspection was carried out on 23rd June 2006.

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 no outstanding requirements from the previous inspection report, but made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Apna House 10/08/07

Apna House 24/03/06

Apna House 06/10/05

Apna House 22/02/05

Apna House 26/11/04

Apna House 22/03/04

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

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

CARE HOME ADULTS 18-65 Apna House 6 Park Avenue Hockley Birmingham West Midlands B18 5NE Lead Inspector Julie Preston Unannounced Inspection 23rd June 2006 12:00 Apna House DS0000016857.V300186.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 Apna House DS0000016857.V300186.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. Apna House DS0000016857.V300186.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Apna House Address 6 Park Avenue Hockley Birmingham West Midlands B18 5NE 0121 551 5678 0121 554 4322 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) Apna House Ltd Miss Hina Parmar Care Home 13 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (13) of places Apna House DS0000016857.V300186.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Residents must be aged under 65 years That the home provides personal care only for 13 people for reasons of mental disorder, excluding learning disability or dementia. The home can accommodate three named residents over the age of 65 years, whilst the home can meet their needs. The home must ensure that these named individuals needs are reviewed regularly, and a record made of this review. The home can accommodate one named individual who has a dual diagnosis. That Mrs Parmer provides evidence of completion of NVQ level 4 in care and management by April 2005. 24th March 2006 4. 5. Date of last inspection Brief Description of the Service: Apna House is sited in the Hockley area of Birmingham. It is well served by public transport affording access to the locality, Birmingham city centre and surrounding areas. The home is close to shopping facilities including specific cultural provision. Nearby are temples, mosques and churches attendant to all faiths represented at the home. Care is delivered in a large, refurbished double fronted house having tarmac frontage, ramped and stepped access to the main entrance and a small patio/garden at the rear mostly laid with tarmac and some small raised lawns. The home provides care, rehabilitation and recovery services to up to 13 adults who are experiencing problems with their mental health. It was reported that service users whose first language is not English are able to converse with staff that will also advocate for them in their first language. The home currently accommodates male service users presenting a diverse range of mental health problems. Specific cultural needs are met through the provision of separate facilities for the storage and preparation of culturally appropriate food and adaptations to shower facilities for preparations prior to prayer. There are established links to other relevant professionals involved in mental health recovery services. Apna House DS0000016857.V300186.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key fieldwork took place over two half days and included discussion with service users about the care they receive in the home and sampling of the documents that describe their needs and routines. Visiting mental health care professionals made positive comments about the conduct of staff and their approach in supporting service users to maintain their independence. Some policies and procedures were looked at as well as staff training and recruitment records. A tour of the premises took place and systems of medicine management were examined. There have been no complaints about this home since the last inspection. What the service does well: What has improved since the last inspection? Care planning and risk assessment is better so that service users needs are more clearly recorded. This helps staff to have a greater understanding of individual’s needs. Service users are invited to attend meetings to discuss the running of the home. Apna House DS0000016857.V300186.R01.S.doc Version 5.2 Page 6 Activity planning has helped service users choose things they would like to do each week. A refrigerator has been purchased for safer storage of medicines. Staff have made effort to produce information about making complaints using language that service users understand. New floor coverings in the kitchen, ground floor shower room and smoke room have been fitted which enhances the appearance of these rooms. The management of the home has improved which creates better outcomes for service users. 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. Apna House DS0000016857.V300186.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 Apna House DS0000016857.V300186.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 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. There are effective systems in place to assess the needs of prospective service users before they move into the home. EVIDENCE: Records of admission were observed for one service user who moved into the home in 2005. An assessment had been completed using the homes written guidance and included input from other professionals involved in the person’s care. It was evident from daily and care records that a number of trial visits had taken place prior to admission and that the service user had been consulted about moving into the home. Apna House DS0000016857.V300186.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 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are met through effective systems of care planning and risk assessment. Service users are supported to make decisions about their lifestyles. EVIDENCE: Three care plans were sampled during this visit. It was pleasing to note that all had been reviewed within the last month and included input from the service user and professionals involved in their care. The care plans were detailed and provided clear information about service users assessed needs and preferred routines; dated and signed by the person responsible for their completion. One service user commented that his personal goals had been respected by staff and that he enjoyed going out alone as a result of his care plan review. Apna House DS0000016857.V300186.R01.S.doc Version 5.2 Page 10 Care plans were seen to be linked to risk assessments, which identified the controls in place to manage known risks. For example written agreements had been drawn up to remind service users of risk management strategies in accordance with their individual needs. A number of service users travel independently and spend time out of the home without staff support. Assessments were observed that described the individual’s skills and needs as a means of promoting independence and personal safety to enable them to take part in these activities. Staff present during this visit were able to describe the care and support they provide to service users, which was consistent with the care plans sampled. Service users were observed to make decisions about where they spent their time and whether they participated in planned activities. Two service users talked about their enjoyment of visiting places of worship on a regular basis. During this fieldwork a number of service users chose to go to their local mosque for prayers. The home has begun regular service user meetings, records of which were seen at this visit. It was evident from observation of the records and discussion with service users that the meetings have assisted the way in which people who live in the home make decisions about the way the home is run. For example, consultation regarding rules about smoking and the development of the complaints procedure into a more accessible format. Apna House DS0000016857.V300186.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 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported to take part in activities they have chosen and enjoy and maintain contact with their friends and relatives. Service users cultural needs are understood and met by the staff team. EVIDENCE: Since the last inspection, activity planners have been developed for each service user, samples of which were observed at this visit. One service user commented that he was having a review with staff and his relatives to plan further activities, which he was looking forward to. Another service user said that he made choices about the things he did each day such as doing his own cooking and shopping, going for walks and to the mosque every day. Apna House DS0000016857.V300186.R01.S.doc Version 5.2 Page 12 Daily records sampled showed that service users took part in a number of community based activities including trips to the cinema, shopping centres, attendance at college courses, work placements and cafes and restaurants. All of the service users who were spoken to during this visit made positive comments about their opportunities for contact with friends and relatives. One person stated that the home provides transport for him to visit his relatives on a regular basis. Others described inviting relatives and friends to social events, reviews and for meals at the home. A number of service users visit local places of worship each week and staff confirmed that friendships had been made as a result of the visits. Service users were observed moving freely around their home, spending time in their bedrooms, lounges and the garden. Discussion with service users, staff and observation of risk assessment records identified that individuals are offered a key to their bedroom doors, unless the outcome of the risk assessment deems it unsafe to do so. The home has a large dining area with sufficient space for service users to eat together and a small kitchen that is used by individuals to prepare their own meals and snacks. Food storage was examined in the main kitchen, where supplies were noted to be plentiful and varied. Suitable storage facilities are provided for stocks of Halal products and the kitchen staff demonstrated awareness of service users cultural needs with regard to food. The records of food consumed by service users were sampled. In some cases the records had not been completed and it was not possible to establish what individuals had eaten. This needs to be improved to ensure that accurate records are maintained for the benefit of all service users and particularly those with additional health care needs such as diabetes. Apna House DS0000016857.V300186.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 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Service users receive support to manage their personal and health care according to their needs and preferences. Medicine management is generally good. The provision of training to staff will improve this process. EVIDENCE: Three personal care plans were sampled. All detailed service users preferred routines and the support each person needed to complete personal care tasks. It was pleasing to note that care plans referred to providing same gender staff support to assist with personal care in accordance with service users wishes. Some service users commented that this took place. Service users were observed to be dressed according to their age, gender and cultural needs. Apna House DS0000016857.V300186.R01.S.doc Version 5.2 Page 14 Two social workers present during this fieldwork complimented the staff team with regard to their practice in providing culturally sensitive personal care to service users. Service users are registered with a local GP, dentist and optician as needed. It was evident from observation of individual records that RMO’s take a lead role in the review of individual’s mental health care plans. Care plans were in place to describe the action to be taken in response to individual physical health care needs such as diabetes and asthma. Staff were able to describe the action they would take in response to problems, which was consistent with the information recorded in the care plan. It was noted that service users health care appointments were included in their daily records, which made it difficult to track the frequency of contact and the outcome of each appointment. It is recommended that health care records be kept separately to enable issues to be identified promptly without scrolling through other records. Medication was seen to be securely stored. Since the last inspection a new refrigerator has been installed to store some medicines. Two service users medicines were tracked. There were no anomalies between the stock received and the amount dispensed. Protocols for the administration of PRN (as required) medicines were observed. Staff were able to describe the circumstances under which such medicines should be administered. One service user (who’s medicines were tracked) self administers his medication. A risk assessment was seen to be in place to support this and the service user commented that he appreciated this responsibility. Some staff have not received accredited training in the administration of medication. This is required to ensure that service users receive their medication in a safe manner. Apna House DS0000016857.V300186.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 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Effort has been made to produce a complaints procedure that is accessible to service users. Service users understand that they will be listened to when raising concerns within the home. Training in adult protection has not been provided to all staff to ensure that they understand and act upon the procedures in place to protect service users. EVIDENCE: The home has a complaints procedure, which has been developed so that it is presented in the first languages of service users living in the home. This was pointed out to the inspector by a service user during this visit. Three service users explained their understanding of the complaints procedure and commented that they would speak to the registered manager or a member of staff if they were unhappy with anything that happened in the home. One service user raised a complaint about his activity plan during this fieldwork. Staff were observed to take time to talk to him about his concerns and were sensitive in reminding him that a review had been scheduled to deal with this. The home has a copy of the multi agency guidelines issued by Birmingham City Council, which explains how to respond to allegations of concern about actual or possible abuse. Apna House DS0000016857.V300186.R01.S.doc Version 5.2 Page 16 The registered manager confirmed that a number of staff have not received training in adult protection, which was evident from the staff files sampled. This is required to promote the protection of people living in the home and to ensure that staff are aware of their role in this process. Apna House DS0000016857.V300186.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 30 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally clean and homely although a number of maintenance issues require action to create a more pleasant environment for service users to live in. EVIDENCE: The home is a large; double fronted building with gardens to the rear and has off road parking facilities. The premises are in keeping with other properties in Park Avenue and close to local facilities and services. A tour of the home took place at this fieldwork, which identified some concerns about the premises. In bedroom number 11 on the second floor a number of items were seen to be stored, which did not belong to the service user (Christmas decorations and an old table top). These items must be removed. Apna House DS0000016857.V300186.R01.S.doc Version 5.2 Page 18 In this room and in bedroom number 12 written labels (in English) were attached to chests of drawers. It could not be evidenced that they were provided for the benefit of each person. A broken towel rail was noted in bedroom number 3 and the carpet was coming away from the wall in bedroom number 5. This carpet had some burns from cigarette ends. This must be replaced. The walk in shower on the first floor had a number of cracked tiles and the extractor fan in the bathroom on the same floor was dirty. The bath in this room had cigarette burns on it. In the garden a number of items were observed which need to be disposed of, such as a shower chair, rusty table and bags of rubbish. In the ground floor shower room bars of soap and cotton towels were seen. It could not be evidenced that the items belonged to an individual, which poses a risk of cross infection. The extractor fan in the small kitchen leading off the dining room was dirty and the tiles near the cooker in this room were cracked and stained. The inspector discussed these concerns with the registered manager and was advised that a maintenance person was due to be employed in mid July 2006, which she hoped would address some of these issues. There had however been some improvements to the presentation of the home such as new flooring in the kitchen, ground floor shower room and smoke room. It was reported that windows were due to be refitted and a number of radiator guards fitted to reduce the risk of scalding accidents. In the main the home was clean and free from unpleasant odour. Apna House DS0000016857.V300186.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, 34, 35 The quality outcome in this area is poor. This judgement has been made using available evidence including a visit to this service. Staff have not received training to enable them to meet the needs of service users living in the home. Recruitment and selection procedures need further development for the protection of service users living in the home. EVIDENCE: Staff were observed working with service users in a manner considered to be friendly and respectful. It was pleasing to note that 1:1 support continues to be provided to a service user who requires this level of assistance. A number of service users do not have English as a first language. Staff were observed to have the skills to communicate with service users in their first languages. Staff training records were sampled which showed that the majority of staff had not received mandatory nor service user specific training. The registered manager stated that staff training was an area she believed to be in need of improvement and confirmed her commitment to doing so. Apna House DS0000016857.V300186.R01.S.doc Version 5.2 Page 20 Staff training records identified a lack of training in numerous areas. There was no evidence that staff had received training in health and safety, moving and handling, basic food hygiene, first aid, adult protection, infection control, challenging behaviour and mental health care awareness. From observation of staff recruitment and selection records, induction training had not taken place for some newly appointed staff. Those induction records sampled showed that some new staff had not completed a full induction to work within the home and some parts of the induction record had been left blank for other staff. Staff recruitment records sampled showed that in the main, checks had been made of the persons’ suitability to work within the home prior to their employment, including CRB (Criminal Records Bureau) checks, evidence of proof of identity and two written references. In one case, gaps in the person’s employment history recorded on the application for employment form had not been followed up by the home. This must take place to ensure that service users are protected by robust systems of recruitment and selection. Apna House DS0000016857.V300186.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 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Management of the home has improved to create better outcomes for service users, although some areas of health and safety practice are in need of development. EVIDENCE: The home has a registered manager who has been in post for five years and has completed her Registered Manager Award. It was evident at this visit that improvements have been made to service delivery, which creates better outcomes for service users. The registered manager expressed her commitment to driving further improvements. Since the last inspection the registered manager has been offered regular supervision from her line manager, which she stated was beneficial to her professional development. Apna House DS0000016857.V300186.R01.S.doc Version 5.2 Page 22 The inspector was shown questionnaires that had been developed as part of the home’s quality assurance process. Written responses had been completed by visiting professionals and included comments such as “an excellent home” and “professional and friendly staff”. In addition the registered manager confirmed that regular visits are conducted to the home by a representative of the registered provider after which a report is produced commenting on the standard of care delivered. Copies of these reports have been sent to the CSCI. The registered manager demonstrated awareness of the need to have internal procedures to measure and improve the quality of care and confirmed that this area of work is being developed by the organisation. Health and safety records were examined which showed that in the main fire, electrical and gas equipment had been tested and serviced on a regular basis. It was however noted that a fire drill had not been conducted since September 2005 and there was no evidence of Legionella testing in place. The home’s 5 year electrical certificate had expired in 2005 according to the records seen and the home must ensure that an up to date certificate is made available for inspection. Records were sampled which showed that staff had recorded injuries to service users as a result of accidents in the home and had taken appropriate action in response. In two cases there were no records reporting accidents to the CSCI as is required by regulation. Apna House DS0000016857.V300186.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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 2 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 1 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 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 3 X X 2 X Apna House DS0000016857.V300186.R01.S.doc Version 5.2 Page 24 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA17 Regulation 17(2) Sch 4(13) Requirement Records of food consumed by service users must be completed in sufficient detail to enable the reader to determine that the diet is satisfactory and reflective of specific dietary needs. Staff must receive accredited training in the safe handling of medicines. Staff must receive training in adult protection. The items stored in the garden must be disposed of. Items stored in bedroom number 11 that do not belong to the service user must be removed. The broken towel rail in bedroom number 3 must be repaired or replaced. The carpet in bedroom number 5 must be replaced. Written labels on the furniture in bedrooms 11 and 12 must be removed if they are not present for the benefit of service users. Bars of soap and communal towels must be removed from shower/bathrooms. Timescale for action 30/09/06 2 3 4 5 YA20 YA23 YA24 YA26 18(1)(a) 13(2) 18(1)(a) 13(6) 16(2)(k) 23(2)(l) 30/10/06 30/10/06 30/09/06 30/09/06 6 7 8 YA26 YA26 YA26 23(2)(c) 23(2)(d) 12(4)(a) 30/09/06 30/09/06 30/09/06 9 YA30 13(3) 30/09/06 Apna House DS0000016857.V300186.R01.S.doc Version 5.2 Page 25 10 YA30 23(2)(d) 11 YA34 7,9,19 Sch2, 4 18(1)(a) 12 YA35 13 YA42 23(4)(e) The extractor fan in the small kitchen must be cleaned and the tiles in this room repaired or replaced. Staff recruitment records must be maintained in accordance with the Care Homes Regulations. A review of staff training must be conducted to ensure that all staff receive both mandatory and service user specific training. A copy of this review must be made available for inspection. Fire drills must be conducted at least every six months and the outcome recorded. Immediate requirement Incidents affecting the well being of service users must be reported to the CSCI in accordance with this regulation. The home must ensure that the 5 year electrical certificate is updated and provide evidence of Legionella testing. 30/09/06 30/09/06 30/09/06 30/06/06 14 YA42 37 30/09/06 15 YA42 13(4)(c) 30/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA19 Good Practice Recommendations Consideration should be given to storing service users health care records separately to their daily records. This will enable staff to identify continuing health care issues more effectively. Apna House DS0000016857.V300186.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Apna House DS0000016857.V300186.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. 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