Inspection on 27/04/06 for Athelstan House

This inspection was carried out on 27th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 19 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Athelstan House 18/06/09

Athelstan House 17/07/08

Athelstan House 11/09/07

Athelstan House 22/11/06

Athelstan House 13/12/05

Athelstan House 21/02/05

Athelstan House 13/08/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Athelstan House Athelstan House 42 Hanworth Road Feltham Middlesex TW13 5AY Lead Inspector Mrs Rekha Bhardwa Unannounced Inspection 27th April 2006 10:05 Athelstan House DS0000051552.V292260.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 Athelstan House DS0000051552.V292260.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. Athelstan House DS0000051552.V292260.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Athelstan House Address Athelstan House 42 Hanworth Road Feltham Middlesex TW13 5AY 020 8890 3957 020 8844 0457 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) Mr Paul Martin Harrington Mrs Rosemary Wairimu Harrington Mr Brian Robert Bailey Care Home 5 Category(ies) of Learning disability (5), Physical disability (2) registration, with number of places Athelstan House DS0000051552.V292260.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th December 2005 Brief Description of the Service: Athelstan House is a registered care home for five younger adults with learning disabilities. It is situated on a residential street and is within short walking distance to local amenities, buses and trains. There are five bedrooms in the home all fitted with en suite facilities. Two of the bedrooms are on the ground floor and three are on the first floor of the house. There are also separate bathroom facilities on each floor. There is one separate lounge and a lounge/dining area for service users. All areas were appropriately furnished. There is a large well maintained garden at the rear of the home. Athelstan House DS0000051552.V292260.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of 3.30hours was spent on the inspection process. The Inspector carried out a tour of the home, inspected service user plans, servicing records, medication records and staff records. The Inspector met with two service users on the day of the inspection, the Registered Providers and one support worker who is the Son of the Registered Providers. All the service users have Learning disabilities and only one of the two service users was able to communicate verbally. At the time of the inspection the two residents were living at the home. The Registered Manager had left and little progress had been made in recruiting a new Registered Manager. The Registered Provider’s were both working in the home full time. It is acknowledged that the home has been open since February 2004 and that no service users have been accommodated at the home until September 2005. The pre-inspection questionnaire given to the home at the time of the inspection has been used to inform this inspection. This inspection highlighted a number of shortfalls that must be addressed. What the service does well: What has improved since the last inspection? There are several requirements that have been repeated at this inspection. Progress has been made in recording the food partaken by the service users. Improvements have also been noted in the management and recording of Athelstan House DS0000051552.V292260.R01.S.doc Version 5.1 Page 6 medication. Appropriate information on the provision of advocacy services is available. 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. Athelstan House DS0000051552.V292260.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 Athelstan House DS0000051552.V292260.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 Service users are not fully assessed prior to admission to ensure that the home can meet their needs. EVIDENCE: There were two service users being accommodated in the home at the time of the inspection. One service user had been admitted to the home as an emergency placement in December 2005. The home had not received a Needs Led Assessment (NLA) from Hounslow Community Physical Learning Disability Team as no NLA assessment had been undertaken by the Social Worker. Where a service user has been admitted as an emergency admission the home must obtain a completed Needs Led Assessment within five days of admission. The Registered Provider had carried out there own assessment following referral and this was comprehensive. Athelstan House DS0000051552.V292260.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 There is a care planning system in place, service user plans do not always reflect how the needs of service users are to be met. Shortfalls in undertaking periodic reviews does not allow the home to always meet the changing needs of service users. Shortfalls in the management of service users personal allowances, do not safeguard the service users. The home has a good risk management system in place, which protects the safety of the service user. EVIDENCE: Service user plans were available for both service users. These were generally well detailed and provided information on how the assessed needs of the service users were to be met, this included details of how activities of daily living were to be met. Shortfalls were identified with one service user plan where there was no plan in place detailing how the service users aggressive behaviour would be dealt with. There was no evidence of a review following a three month ‘settling in’ period of the most recently admitted service user and Athelstan House DS0000051552.V292260.R01.S.doc Version 5.1 Page 10 this was discussed with the Registered Provider. Moving and Handling risk assessments were not available for both service users. For one service user who was at risk of falling a falls risk assessment was available. Records of GP visits are recorded on the homes computer. It was suggested at the time of the inspection that a record be kept in each service users file. Daily recordings are completed on each shift. Staff were observed offering choices and acknowledging any decisions that were being made by the service users. Information was available on local advocacy groups that were available in the local area. This was displayed on the resident’s notice board, which is in the staff office. The Inspector recommended that this be moved into an area that is used by the service users. None of the service users are able to manage their own finances. Records viewed detailed income and expenditure. Receipts were also available. A residents finance procedure was available. The Inspector noted that personal allowances for service users are paid into the homes business account. This is poor practice and the need to have a separate account as a matter of priority was discussed with the Registered Provider. One service user is able to sign for any money that is received for small personal items. Individual risk management plans are also in place for individual service users. At the time of the inspection none of the service users were able to go out unaccompanied and this was clearly recorded in the service user plan. Athelstan House DS0000051552.V292260.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 & 17 Activity provision is poor and the service users in the home are not able to enjoy a variety of appropriate individual activities. This does not meet their assessed needs and does not enhance their quality of daily life. EVIDENCE: The home accesses local amenities that are suitable for the service users to access and meet their individual needs. Opportunities for individual development of the service user are addressed via the service user plan. None of the service users are able to take up opportunities for employment, education or voluntary work due to the nature of their learning disability. None of the service users are able to attend day care. One service user had started attending a drop in centre but this had not been suitable for their needs. There is no activities programme in place. Activities undertake include shopping, drives to Windsor, Bushey Park and other local places of interest. Athelstan House DS0000051552.V292260.R01.S.doc Version 5.1 Page 12 Service users listen to music and spend time in the garden. At the time of the inspection no visits by families or friends were being undertaken. Little progress in this are has been made in the area of activity provision specific to the assessed needs of the service user. The Registered Manager informed the Inspector that service users are involved in deciding what meal is to be prepared on a daily basis. A record of the food being provided was being maintained. Service users participate in shopping and purchasing items for the meal to be prepared. The kitchen was viewed and found to be clean and well ordered; fridge/freezer temperatures were being recorded daily. For one service user who preferred an Asian diet the home were taking this service user to the local Gurdwara for a meal. The Registered Provider commented that they were in the process of having an additional carer on duty at the weekend who would plan, assist and help the service user prepare an Asian meal. The service user was able to confirm to the Inspector that the food was satisfactory even though an Asian diet was not provided daily. Service users can access the laundry and kitchen areas when accompanied by a staff member. All bedroom doors are lockable and their was evidence that service users receive their mail unopened. Athelstan House DS0000051552.V292260.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 & 20 Service users moving and handling needs are not assessed and this potentially places the service user at risk. Generally the service users personal care needs are met in the way service users prefer and require. Service users health care needs are met and service users have access to healthcare professionals, thus ensuring that their healthcare needs are met. Generally medications are well managed, thus safeguarding service users. The one shortfall in this area should be easy to address. EVIDENCE: There was no evidence that the service users moving and handling needs had been assessed. The service users have a flexible routine and this includes what time they get up, go to bed, meal times and the level of participation in the home. Details of how individual personal support is provided were detailed in the service user plan. The staff encourage service users to be as independent as possible and offer support and guidance as required by the individual. Athelstan House DS0000051552.V292260.R01.S.doc Version 5.1 Page 14 Both service users have been registered with a GP in the local area. Details of other healthcare professionals involved in the service users care were detailed in each service users file. Where service users had attended the GP details were kept on an electronic calendar and not on the individual file. Staff assist service users to attend hospital appointments and other appointments. Any healthcare professional visits undertaken at the home take place in private. A medication procedure was available. At the time of the inspection there were no Controlled Drugs in use. Medication Administration Records viewed were well-completed and detailed receipts and disposal of medication. Dates of opening were not recorded on liquid medications and this was discussed with the Registered Provider. Medication is stored in a lockable filing cabinet. Athelstan House DS0000051552.V292260.R01.S.doc Version 5.1 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 and 23 The home has in place an effective complaints procedure, this ensures that service users views and concerns are listened to and addressed. The home does not have the systems in place for the protection of vulnerable adults, thus service users are not safeguarded. EVIDENCE: A complaints procedure is available, both in written and pictorial form. There have been no complaints received by the CSCI or the home since the last inspection. The home has in place alleged abuse guidelines. These are not procedures and do not meet the National Minimum Standards for Younger Adults. The home is required to have Protection of Vulnerable Adults Procedures in place, which dovetail with the Local Authority procedure. The homes procedure must also include Whistle Blowing and details of the Department of Health No Secrets guidance. The Registered Provider informed the Inspector that the home does have a copy of Hounslow’s multi agency Protection of Vulnerable Adults policy and procedure. Training records indicated that none of the Registered Providers or their Son had received training in the Protection of Vulnerable Adults. Athelstan House DS0000051552.V292260.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 29 and 30 The standard of the environment is generally good and provides service users with an attractive and homely place to live. Shortfalls in wedging the doors open potentially place service users at risk. Service users individual bedrooms are personalised and suit their individual preferences. Shortfalls in providing the service users with suitable adaptations and equipment does not maximise the service users independence and choice. EVIDENCE: The Inspector undertook a tour of the premises. The home was well maintained, clean and hygienic. Individual bedrooms viewed were personalised and met service users individual needs and preferences. Furnishings were of a good standard throughout. The home is close to local amenities which include Feltham High Street, railway station, main bus route and leisure complex. All service users bedrooms have a lockable facility. Communal areas are homely and equipped with TV, music system and video player. Service users Athelstan House DS0000051552.V292260.R01.S.doc Version 5.1 Page 17 can access the rear garden via the lounge, and the garden is welcoming and well maintained. The Inspector noted that several of the bedroom doors were wedged open this is a potential fire hazard. The need to have an automatic door closure where service user wished to have their bedroom doors kept open was discussed with the Registered Provider. No progress has been made in arranging for an Occupational Therapist to assess the home to ensure that the home has appropriate aids and equipment in place to maximise the independence of the service users. This is a repeat finding. The ramp from the lounge to the garden has no handrail. One service user has mobility problems. Athelstan House DS0000051552.V292260.R01.S.doc Version 5.1 Page 18 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 The home had in place minimum levels of staff to meet the needs of service users. Staffing levels need to be reviewed to ensure that service users needs are individually met. The vetting and recruitment practices are poor and do not safeguard the service users. Shortfalls in staff receiving training potentially place the service users at risk of not having their individual and joint needs being met. EVIDENCE: At the time of the inspection the Registered Providers and their Son were working in the home. No other staff had been employed. The Registered Manager had left and no plans were in place to recruit a new Manager. No duty rosters are kept and this was discussed with the Registered Provider at the time of the inspection. It was clear from the records viewed that all three staff had not received recent training relevant to the work that they were undertaking. No recent and up to date training had taken place in relation to health and safety, first aid, moving and handling and adult protection. There was no training or development programme in place. Athelstan House DS0000051552.V292260.R01.S.doc Version 5.1 Page 19 This is a repeat finding and an immediate requirement was issued at the end of the inspection. Correspondence has been received from the Registered Provider detailing how they are addressing this immediate requirement. It was not clear what specialist skills the staff had in meeting the individual needs of service users. This included communication skills and management of challenging behaviour. The Registered Providers Son had recently started working at the home. A POVA First had been obtained. No other records in relation to his working at the home had been obtained. This included an application form, photograph, proof of identity, two references and a medical declaration. This again is a repeat finding. Athelstan House DS0000051552.V292260.R01.S.doc Version 5.1 Page 20 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 and 42 The home does not review aspects of its performance through a programme of self-review and consultation and seeking the views of service users, staff and relatives. The Health and Safety systems in place in the home are poor and need to be reviewed to ensure that the safety of the service users, staff and visitors to the home is maintained at all times. EVIDENCE: The Registered Manager had left the home prior to the last inspection in December 2005. The Registered Providers were working in the home full time. No progress had been made in recruiting a new Manager. The Registered Provider stated that the home had been open since February 2004 and that service users had only been placed by the Local Authority since September 2005. The Registered Provider stated that the home was financially viable. Athelstan House DS0000051552.V292260.R01.S.doc Version 5.1 Page 21 No progress has been made with the implementation of an effective quality assurance and quality monitoring system. This is a repeat finding from the last inspection. Several of the requirements from the last inspection have not been addressed and have been restated in this report. Servicing records were viewed at random and the Inspectors findings indicated that this are had been poorly managed. The fire alarm had not been serviced since 20/11/03. No portable appliance testing had taken place since the home opened. No legionella testing had been undertaken. Thermostatic valves had not been fitted to the baths and there was no evidence that hot water temperatures are monitored. Risk assessments in relation to hot water were not available. The fire risk assessment viewed was brief and had not been completed using the guidance issued by the London Fire Emergency and Planning Authority. An immediate requirement was issued at the end of the inspection in relation to the fire alarm panel. Correspondence has been received from the Registered Provider in relation to this immediate requirement following the inspection. Fire drills and weekly fire alarm test had been undertaken. Athelstan House DS0000051552.V292260.R01.S.doc Version 5.1 Page 22 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 2 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 1 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 2 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 1 35 1 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 2 X 1 X X 1 x Athelstan House DS0000051552.V292260.R01.S.doc Version 5.1 Page 23 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA2 Regulation 14 Requirement Where a service user has been referred via care management a copy of the Needs Led Assessment must be obtained prior to the service users admission to the home. Where a service user has been admitted as an emergency admission the home must obtain a copy of the Needs Led Assessment within five days of the service user moving into the home. Moving and handling risk assessments must be available for all service users. The service user plan must be periodically reviewed and updated to reflect any changes. The service user plan must detail interventions required in managing service users aggressive behaviour. Timescale for action 01/06/06 2 3 4 YA6 YA6 YA6 13(5) 15 15 01/06/06 01/06/06 01/06/06 5 YA7 20 6 YA14 Service users personal allowance monies must not be kept within the homes business account. 16(2)(m)(n) The home must provide varied and appropriate social and DS0000051552.V292260.R01.S.doc 01/06/06 01/06/06 Athelstan House Version 5.1 Page 24 leisure activities for service users. (previous timescale 01/02/06 not met) 7 8 YA20 YA23 13(2) 13(6) Dates of opening must be recorded on liquid medications. The homes guidelines for the Protection of Vulnerable Adults must be updated in conjunction with no secrets and dovetail with the Hounslow’s MultiAgency Adult Protection documentation. All staff working in the care home must receive training in the Protection of Vulnerable Adults. Bedroom doors must not be wedged open. An automatic door closure must be fitted to bedroom doors where the service user wishes the door to be kept open. An assessment of the home must be carried out by an appropriately trained person to ensure the home has appropriate aids and equipment in place. (previous timescale 01/03/06 not met) All of the information outlined in Schedule 2 of the Care Homes Regulations 2001 must be obtained for all staff working at the home. (previous timescale 01/02/06 not met) Appropriate training must be provided to ensure staff have the appropriate skills to carry out their duties. (previous timescale of 1/10/05 not complied with, immediate requirement issued) The Registered Provider must send written confirmation to Athelstan House DS0000051552.V292260.R01.S.doc Version 5.1 Page 25 01/06/06 01/07/06 9 YA23 13(6) 01/06/06 10 YA24 12 01/06/06 11 YA29 23(2)(n) 01/07/06 12 YA34 19(1)(b) 01/06/06 13 YA35 18(1) 28/04/06 the CSCI by midday on Friday 28th April 2006 details of training dates, the names of staff attending the training and details of the training to be undertaken. 14 YA37 8 Appropriate management arrangements must be made for the home. (previous timescale 01/04/06 not met) A quality assurance system must be developed for the home. (previous timescales of 1/12/05 and 01/03/06 not complied with) The Registered Provider is required to ensure that the fire alarm is regularly serviced. Servicing documentation must be available for inspection. The Registered Provider must provide written confirmation by 12 midday on Friday 28th April 2006 of when and by whom the fire alarm is to be serviced. (Immediate requirement issued) Regular servicing of the equipment provided in the home must be undertaken. Documentary evidence of this must be available at the home for inspection. Health and Safety systems must be in place. The fire risk assessment must be updated and a copy maintained at the home for inspection. Risk assessments on bathing and hot water must be available. 01/08/06 15 YA39 24(1) 01/08/06 16 YA42 23(2) 28/04/06 17 YA42 12 23(2) 01/06/06 18 YA42 23(4) 01/06/06 19 YA42 12 01/06/06 Athelstan House DS0000051552.V292260.R01.S.doc Version 5.1 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. Refer to Standard Good Practice Recommendations Athelstan House DS0000051552.V292260.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection 11th Floor West Wing 26-28 Hammersmith Grove Hammersmith London W6 7SE 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 Athelstan House DS0000051552.V292260.R01.S.doc Version 5.1 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. 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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