Inspection on 12/01/07 for Ardgowan House

This inspection was carried out on 12th January 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ardgowan House 15/09/08

Ardgowan House 09/10/07

Ardgowan House 03/07/06

Ardgowan House 16/01/06

Ardgowan House 22/07/05

Ardgowan House 28/02/05

Ardgowan House 02/09/04

Ardgowan House 27/02/04

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

CARE HOME ADULTS 18-65 Ardgowan House 4 Middle Street Newsham Blyth Northumberland NE24 4AB Lead Inspector Karena M Reed Key Unannounced Inspection 12th January 2007 11:15 Ardgowan House DS0000000521.V320709.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 Ardgowan House DS0000000521.V320709.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. Ardgowan House DS0000000521.V320709.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ardgowan House Address 4 Middle Street Newsham Blyth Northumberland NE24 4AB 01670-367072 01670 367072 deborah.jobson1@btinternet.com 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) Mrs A Jobson Mrs A Jobson Care Home 13 Category(ies) of Learning disability (1), Mental disorder, registration, with number excluding learning disability or dementia (7), of places Mental Disorder, excluding learning disability or dementia - over 65 years of age (5) Ardgowan House DS0000000521.V320709.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th October 2006 Brief Description of the Service: Ardgowan House is a home registered to provide personal care to thirteen adults. Categories of registration include eleven places for adults with mental health problems, five of these places are for people over sixty-five years of age and one place is for an adult with learning disabilities. The home is situated in a residential area on the outskirts of Blyth. It is close to local shops and pubs. The town centre and coast are also nearby. The home does not provide nursing care. The home consists of a large detached house with a small front and very large rear garden. All bedrooms are for single occupancy. There is a dining room/combined lounge, separate lounge, conservatory and a quiet room. A passenger lift is not available but some bedrooms are located on the ground floor of the property. There are two bathrooms, two shower rooms and sufficient lavatories for the needs of residents. A bathroom and shower room are fitted with equipment to assist physically dependent people. Fees payable for living at the home at the time of inspection in January 2007 vary between £359 and £370.45. Additional charges are payable for hairdressing, private chiropody, holidays, personal toiletries and newspapers. Ardgowan House DS0000000521.V320709.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was unannounced and took place over four and a half hours. A partial tour of the premises took place and a sample of records were inspected which included: 4 care plans, 2 residents contracts, 2 personal allowance records, the fire log, accident book, admission /discharge book, complaints record, staff communication book, staff meeting minutes, the medication system and five staff files. The deputy manager, one support worker and five residents were interviewed at the time of inspection. What the service does well: What has improved since the last inspection? An office has been made so residents may enjoy their own living space rather than records being stored in residents living areas. A nurse call system has been installed so residents may ring for help if required. There is an on going programme of decoration and refurbishment around the home so residents may enjoy comfortable and safe surroundings. Staffing duties have been reviewed to ensure enough staff are available to provide care and support to residents at busy times of the day. Staff supervision is carried out regularly. Ardgowan House DS0000000521.V320709.R01.S.doc Version 5.2 Page 6 A system for the regular reviewing of the care and support needs of residents has been introduced. A record of all food provided to residents is being kept by the home. Ancillary tasks have been altered so they can be carried out at more convenient times to residents. The level of staff training continues to improve to help provide staff with information about the needs of residents. Drinks are now available to residents at all times of the day. The running of the home is becoming less restrictive to residents. What they could do better: Social activities and entertainment should be available to residents at seasonal times especially Christmas and at any other times. A suitable medication cabinet must be stored in a more appropriate place, not in the smoking room. The carpet by the back door near to the bathroom must be replaced. The broken fly screen in the kitchen must be repaired or replaced. The smoking lounge requires decorating due to nicotine staining and the carpet requires cleaning. Chemical products must be kept in a lockable cupboard in the interests of health and safety. All requirements made from inspections must be carried out within the stated timescales. The daily register must record any residents’ overnight stays away from the home. Menus must be formalized and planned weekly, monthly or seasonally. Residents’ contracts made between the home and the resident must be revised and updated to include current scale of charges and terms of residency. The fire log must be kept up to date to show that regular checks have been carried out to ensure the emergency lights are working. Ardgowan House DS0000000521.V320709.R01.S.doc Version 5.2 Page 7 Staff files must record when Criminal Record Bureau checks as part of staff vetting were carried out. An up to date record should be kept of all training that has been completed by staff. Training about ageing should be provided to staff to give them more information about the needs of residents as they become older. Staff should continue to involve residents in the running of the home and their own lives. Staffing levels should continue to be reviewed as residents’ needs change. 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. Ardgowan House DS0000000521.V320709.R01.S.doc Version 5.2 Page 8 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 Ardgowan House DS0000000521.V320709.R01.S.doc Version 5.2 Page 9 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 2,3,4,5 The home collects enough information about the needs of prospective residents before they move in to help ensure staff are aware of the amount of care and support needs of the resident as they settle in. Staff receive a variety of training to give them the knowledge and insight to help understand the needs of residents and to provide the necessary levels of care and support to individual residents. Contracts are out of date and are not relevant to the current circumstances of residents. EVIDENCE: Records for four of the residents showed that when they were admitted to the home an assessment of their care needs had been carried out before their admission. The resident and relevant people who knew them were involved in the initial assessment. This information and the care manager’s assessment of the resident’s care needs were used to ensure all the needs of the resident Ardgowan House DS0000000521.V320709.R01.S.doc Version 5.2 Page 10 could be met by staff. The records contained a range of information. The files had been audited to ensure information available was up to date. Staff receive training so that they know how to meet the specialist needs of the residents. Staff have received the necessary statutory training: Fire Training, Moving & Assisting, Food Hygiene, Safe Handling of Medication, First Aid, Protection of Vulnerable Adults and National Vocational Qualifications. Staff have also received training about; infection control, podiatry training, risk assessment, bereavement, diabetes awareness, person centred planning, epilepsy awareness, activities in the care setting, incontinence and supervision training. Falls awareness training is planned. Residents have the opportunity to visit the home as often as they need in order to decide if they want to live there. A resident may come for meals, have overnight stays and be introduced to other residents at the home at a pace suitable to the individual. Contracts were available on residents’ file but they were out of date and did not give an accurate account of the services and facilities provided to residents. Ardgowan House DS0000000521.V320709.R01.S.doc Version 5.2 Page 11 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 6,7,8,9 There are good arrangements in place to ensure that residents’ health and social care needs are met. There is a system of reviewing the changing care needs of residents. Residents are well supported by staff and care plans show the amount of care and support that staff are providing to residents. Residents are encouraged to be involved in decision-making and to communicate and make their views known. Staff do support residents to take risks as part of independent living. EVIDENCE: There are detailed assessments in the residents’ care plans. Personal support needs are documented and give instructions to staff on how to support people that require support with tasks such as washing, bathing, Ardgowan House DS0000000521.V320709.R01.S.doc Version 5.2 Page 12 dressing and carrying out any assessed tasks to help promote the independence of the person. Care plans are being updated three monthly or earlier if required if a resident’s care and support needs change. Residents care records showed that they have access to external health care services. GPs and Community Nurses were regularly consulted for advice and treatment. Records show residents are assisted to access chiropody, dental and optical services at least annually or as often as required. Residents are asked individually and consulted about decisions involving themselves and the running of the home. Meetings are held weekly with service users about the running of the home. Service users spoken to stated that they were involved and consulted about decisions involving themselves. The home supports residents to remain independent and take risks in order to live a more fulfilled lifestyle and up to date risk assessments were present in residents care records. Ardgowan House DS0000000521.V320709.R01.S.doc Version 5.2 Page 13 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 12,13,15,16,17 Residents are encouraged to take part in age, peer and culturally appropriate activities. Community facilities are used by residents wherever possible. Appropriate leisure activities are usually available for residents. Residents are encouraged to have appropriate personal, family and sexual relationships. Residents’ rights and responsibilities are recognised in their daily lives. Residents are offered a healthy diet. Ardgowan House DS0000000521.V320709.R01.S.doc Version 5.2 Page 14 EVIDENCE: Residents agreed that they are involved in the running of the home and involved in making decisions about their lives. Residents’ records and residents meeting minutes showed that all residents are consulted and asked their opinion and encouraged to make decisions. Conversation with residents showed staff support residents to acquire skills and become more self sufficient in aspects of every day living. Residents all pursue their own individual hobbies and interests. Some residents attend drop in centres and day centres during the week. It was disappointing to find that very little seasonal entertainment had taken place over Christmas and New Year, residents only enjoying a party over New Year as it was someone’s birthday. Within the home residents usually enjoy quizzes, beetle drives, video nights and playing bingo. Residents care plans and case records detail any family involvement. Conversation with residents also provided evidence that they are encouraged to maintain contact with family and friends, staff providing the necessary levels of support for them to do so. Every day residents are asked what they wish to eat. A record was available to show food prepared and served to residents daily. Menus were available but they did not correctly show food provided to residents over a weekly period and in order to allow for the forward planning of the meals. A light snack is available at lunch times and a cooked meal is served in the evening. On the day of inspection homemade broth or cheese jacket potato was available for lunch. Chicken and rice or chicken chasseur, cauliflower, potatoes, carrots and vegetables were being served in the evening. Brandy snaps or passion fruit cheesecake were offered for dessert. Ardgowan House DS0000000521.V320709.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 18,19,20,21 Residents do receive support in the way they prefer and require. There are good arrangements in place to ensure that residents’ health care needs are met. Systems are in place for residents to retain and administer their own medication where appropriate. Residents’ needs regarding old age are quite well handled. EVIDENCE: Four care plans and case records were inspected. The daily records detailed the care and support required for different needs. They reflected the changing needs of service users due to becoming older or due to ill health. The care plans accurately recorded the needs and the care and support provided by Ardgowan House DS0000000521.V320709.R01.S.doc Version 5.2 Page 16 staff. Staff have not received training about the ageing process which would equip them with more knowledge about the care and support needs of the older and more frail residents. Records showed when residents had seen health professionals, for example, doctors and community nurses. Records also showed when residents had seen opticians and dentists. Staff receive training before they administer medication to residents. A system is in place to oversee the medication of residents if they should retain and administer their own medication. An examination of the medication system took place with difficult. The lighting was poor and it was a very smoke filled environment as the medication cupboard is located in the residents’ smoking room. Discussion again took place about its relocation. Ardgowan House DS0000000521.V320709.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 22,23 The complaints procedure was available to remind people coming into the home of their right to complain. Residents are protected from abuse. EVIDENCE: There is a complaints procedure to inform people visiting the home of how they could complain if necessary. Residents have access to a complaints procedure that assists and supports them to bring any matters to the attention of staff outside of the home in case they felt uncomfortable bringing any complaints or concerns to the attention of staff within their home. The home keeps a record of complaints. Staff have received training about Protection of Vulnerable Adults and Prevention of Abuse. Ardgowan House DS0000000521.V320709.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 24,28,30 Residents live in a more homely, comfortable and safe environment. Additional living areas have been created for the benefit of residents. There is a quite a good standard of hygiene around the home. EVIDENCE: There is a programme of redecoration and improvement around the home. Since the last inspection much has been achieved around the home to make it more comfortable and safe for residents and staff. An office has been created which allows all the records, filing cabinets and notices for staff to be moved out of the residents’ dining room and into a more private location. Ardgowan House DS0000000521.V320709.R01.S.doc Version 5.2 Page 19 An aquarium has been added to the home at residents’ request. Residents are able to enjoy additional comfortable communal areas. Plans are in place to ensure the new conservatory will be more effectively heated and therefore be able to be enjoyed by residents throughout the year. Some new furniture has been put in the dining room. The dining room is furnished with sofas and a television as well as tables and dining chairs. There is quite a good standard of hygiene around the home apart from the smoking room that is nicotine stained and needs re-decoration. The carpet here also needs cleaning as it is soiled. The carpet by the backdoor, by the bathroom is marked and looks dirty. Ardgowan House DS0000000521.V320709.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 32,33,34,35,36 Residents’ needs are met by the numbers and skill mix of staff. Systems are in place to ensure residents are in safe hands. There are quite sound recruitment policy and practices in place to protect residents. Staff are trained to meet most of the care needs of residents. A system of supervision is in place for all staff working at the home. EVIDENCE: Examination of staff rotas and discussion with the person in charge and members of the staff team showed that the numbers of staff are as follows: Ardgowan House DS0000000521.V320709.R01.S.doc Version 5.2 Page 21 8.00am- 4.00pm 4.00pm-10.00pm 10.00 pm- 8.00 am staff member. 2 support staff 2 support staff to following day 1 sleep in staff member and 1 waking These numbers include the manager. Staff members carry out cooking and cleaning with the help of residents where possible. At least five residents are now over the age of sixty five, so staffing levels should continue to be reviewed to ensure the needs of residents can be met as individually as possible. The necessary checks are being carried out prior to the workers being appointed. CRB checks are carried out before a person is appointed. There was no record to state when CRBs had been carried out or a way to remind management when they required renewing. Staff stated that they enjoyed working in the home and were observed to be kind, caring and respectful to residents. Residents commented they liked living at the home. They were very positive about the new system that had been introduced to ensure they could help themselves to hot drinks when they wanted. Staff said and their records showed that they also receive advice and /or training in other areas. Staff are enthusiastic about training and enjoy the opportunities provided by management. Out of the eleven staff members 98 percent have achieved NVQS at various levels 2 and 3. Residents have increased care and support needs as they become older. Staff have not had specialist training about the ageing process. Staff have received Fire Training, Moving & Assisting, Food Hygiene, Safe Handling of Medication, First Aid, Protection of Vulnerable Adults and National Vocational Qualifications. Staff have also received training about; infection control, podiatry training, risk assessment, bereavement, diabetes awareness, person centred planning, epilepsy awareness, activities in the care setting, incontinence and supervision training. Falls awareness training is planned. Staff receive supervision every two months from the management team. Ardgowan House DS0000000521.V320709.R01.S.doc Version 5.2 Page 22 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 37,38,39,41,42 Residents’ benefit from a better run home. Residents and staff are benefiting from the ethos, leadership and management approach of the home. Residents are becoming more involved in the running of the home and their lives. The standard of record keeping is improving. The health, safety and welfare of residents are mostly promoted and protected. Ardgowan House DS0000000521.V320709.R01.S.doc Version 5.2 Page 23 EVIDENCE: Two of the management team have completed the Registered Manager’s award. Discussion and observation showed that the management are starting to put the needs of the residents first and there is a less institutionalised environment. Some residents living at the home have lived there for several years and the manager has respected the rights of individuals to remain at the home as their needs have changed. The environment has been adapted and staff have been equipped with better training opportunities to meet these different needs of residents. This is a continual process due to these different, individual needs. Documents detailing fire safety, risk assessments in the environment, water temperatures and statutory records were all up to date and well recorded apart from the daily register did not record the absence from the home of a resident who was away overnight. Testing and observation of the working of the emergency lights is not recorded in the fire log book. Staff training relating to health and safety was up to date and training is being planned to renew any that required updating such as first aid and medication training. Some bottles of cleaning materials were left in the yard rather than being locked up and out of residents’ way. Ardgowan House DS0000000521.V320709.R01.S.doc Version 5.2 Page 24 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 3 4 4 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 3 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 2 3 3 3 x 2 2 x Ardgowan House DS0000000521.V320709.R01.S.doc Version 5.2 Page 25 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 2 Standard YA5 YA17 Regulation 5(1)(a) Schedule 4 17(2) 13 13(2) Requirement An up to date contract must be provided to each resident. A formalized menu system must be established in consultation with the residents An appropriate medication cabinet must be obtained and placed in a more appropriate location. Training about the ageing process must be provided to staff. The smoking lounge must be decorated and the carpet cleaned, the carpet by the backdoor must be replaced. The daily register must be completed accurately. The fire log must be completed accurately and regular checks of the emergency lights carried out. Hazard substances must be kept securely locked away in a COSHH cupboard The broken fly screen in the kitchen must be replaced or repaired. Timescale for action 01/03/07 01/03/07 2 YA20 01/03/07 3 4 YA21 YA24 18c (i) 23(2)(d) 01/03/07 01/04/07 5 6 YA41 YA41 3(d)(e) Schedule 4 14 09/02/07 09/02/07 7 8 YA42 YA42 13(4)c 16(j) 09/02/07 01/03/07 Ardgowan House DS0000000521.V320709.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA8 YA33 YA34 Good Practice Recommendations To continue to consult with residents. To continue to review staffing levels. To establish a record of completed CRB checks to show when they require renewal. 4 YA35 To establish a training database to record all training provided to staff. Ardgowan House DS0000000521.V320709.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Ardgowan House DS0000000521.V320709.R01.S.doc Version 5.2 Page 28 - 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. 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