Inspection on 16/05/07 for Duchess Close

This inspection was carried out on 16th May 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Duchess Close 28/02/07

Duchess Close 21/11/05

Duchess Close 01/06/05

Duchess Close 21/02/05

Duchess Close 02/09/04

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 Duchess Close 5 & 6 Friern Barnet London N11 3PZ Lead Inspector Tom McKervey Key Unannounced Inspection 16th May 2007 10:20 Duchess Close 5 & 6 DS0000010425.V333456.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 Duchess Close 5 & 6 DS0000010425.V333456.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. Duchess Close 5 & 6 DS0000010425.V333456.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Duchess Close 5 & 6 Address Friern Barnet London N11 3PZ 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) 020 8368 7131 www.pentahact.org.uk Adepta Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Duchess Close 5 & 6 DS0000010425.V333456.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th February 2007 Brief Description of the Service: 5 & 6 Duchess Close, is a residential care home for six adults, male and female, who have a learning disability with an autistic spectrum disorder. The home was first registered in November 2000, and was established in partnership with Birnbeck Housing Association and Barnet Council. The home, which was built as part of a larger general needs housing development, on the old Friern Barnet Hospital site, is situated in a quiet culde-sac. The property is comprised of two adjoining semi-detached houses, with through-access on the ground floor. This arrangement provides separate group-living areas, each with their own kitchen-diner, lounge, toilet and bathroom. There is a bedroom on the ground floor, and two first-floor bedrooms in each house. There is space for car parking at the front, and a large garden at the rear of the property. There is a good range of shops, pubs and restaurants nearby, and there is good public transport access to the area. The last inspection report and purpose and function document are available to be viewed in the staff office. The current fee is £416.00 per week. Duchess Close 5 & 6 DS0000010425.V333456.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection and took place over a period of four hours. The manager was present throughout the inspection and fully cooperated in the process. I undertook a tour of the building and spoke with a number of the residents and members of the staff team. I also examined the documentation kept in the home including residents’ case files, staff records and documents pertaining to the running of the home. I would like to thank the manager, residents and staff for their openness and participation during the inspection. What the service does well: The home is well managed and clear leadership is provided for staff, which ensures that the people who live in the home receive good care. There is clear up-to-date information for potential users of the service to make informed decisions about its suitability to meet their needs. There are excellent person-centred care plans to guide staff about how they can best meet residents’ needs in a consistent way. Risk assessments identify potential harm to residents’ welfare. Service user information is handled appropriately which ensures that their confidentiality is respected. . There are well established links with the community and the residents take part in a range of stimulating activities. This provides the opportunity for their personal development. Complaints are clearly recorded and prompt action is taken to ensure that complaints are taken seriously. The home benefits from an experienced stable staff team, which improves the quality of care provided to the residents. Staff receive regular supervision, to support them in caring for the residents and enhances their personal development. Staff receive training which is tailored to providing appropriate care. Duchess Close 5 & 6 DS0000010425.V333456.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Duchess Close 5 & 6 DS0000010425.V333456.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 Duchess Close 5 & 6 DS0000010425.V333456.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is good information provided about the service to enable prospective service users to decide if the home is suitable for their needs. A through assessment is carried out of peoples’ needs before they are admitted to the home. Contracts of the terms and conditions are available in a format that can be understood by the residents. EVIDENCE: The home has an up-to-date statement of purpose, including information about the new manager and his previous experience. The document provides sufficient information to ensure that prospective service users are able to make an informed choice about whether the service can meet their needs. Duchess Close 5 & 6 DS0000010425.V333456.R01.S.doc Version 5.2 Page 9 I examined two residents’ files, which contained comprehensive needs assessments by the placement officer and the home manager prior to admission. Residents’ case files contained a contract of terms and conditions, which was in a pictorial form to ensure that the information is accessible to the resident. The contract was signed by the individual resident or their representatives which ensures their rights are respected. One resident wishes to move on from the home into supported living accommodation. The manager and staff, and the Community Learning Disability Team are in support of this initiative and have assessed that this person is capable of more independent living. However, despite several representations to the Local Authority, there are delays in finding an appropriate placement. There is evidence that this is causing the resident some distress and I was informed that a meeting with Social Services was imminent to urgently address this matter. Duchess Close 5 & 6 DS0000010425.V333456.R01.S.doc Version 5.2 Page 10 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): All these standards were assessed. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. There are excellent care plans for each person living in the home, which provide clear objectives of care and guidance for staff in meeting these objectives. There are good systems in place to involve the residents in the running of the home and to enable and support them in making decisions about their lives. The people who live in the home are enabled to live as independently as possible within a good framework of risk assessment. Information about residents is kept securely to protect their confidentiality. EVIDENCE: Duchess Close 5 & 6 DS0000010425.V333456.R01.S.doc Version 5.2 Page 11 I examined two residents’ records, including their care plans, which were very comprehensive. The care plans were person-centred and reflected current and changing needs. Staff are required to sign to confirm they are familiar with the care plans. The care plans showed thorough assessments of all aspects of the residents’ needs for example family background, religious and cultural needs, physical and mental health, communication and likes and dislikes. Based on the assessment, personal goals were set, and guidance for the staff was clearly documented to ensure that they supported the resident in a consistent way. This includes how to support residents’ sexual needs. There was evidence that care plans were being reviewed regularly to reflect residents’ changing needs. The care plans specified the areas in which the residents can be supported to make decisions about their lives. For example, “How I like to be addressed”, is contained in a “Communications Passport”. There is guidance about how to interpret the wishes of residents who are unable to communicate verbally, by using, for example, objects of reference. I was satisfied through observation, that the staff had a thorough understanding of the residents and how to meet their needs. Regular meetings are held between the staff and the residents to involve them in the running of the home. For example, activities are planned and reviewed and the menu for the week is decided at these meetings. Risk assessments were documented, for example, about road safety, going out alone, using public transport, using the cooker and understanding first aid, which ensures the health safety and wellbeing of service users is taken seriously. Residents’ confidentiality is protected through important files being kept in the office in a lockable cabinet. Information kept on the computer is accessed by a password. Staff who I interviewed, were aware of their responsibilities regarding sharing information about the people who live in the home. Duchess Close 5 & 6 DS0000010425.V333456.R01.S.doc Version 5.2 Page 12 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): All these standards were assessed. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Good opportunities are provided in the home and local community for residents to develop their potential to live rewarding lives. The people who live in the home are encouraged and supported to maintain contact with their families and to express their sexuality. There are good systems in place to protect residents’ rights and they are supported to choose a nutritious diet. EVIDENCE: I examined residents’ activity records. They attend various activities outside the home during the week, either in day centres or local colleges. Examples of Duchess Close 5 & 6 DS0000010425.V333456.R01.S.doc Version 5.2 Page 13 the college programmes they attended were, drama therapy, needlecraft and discussion groups. During the inspection a member of staff went out with a resident on a walk. Every year, each resident has a holiday, usually in pairs or singly with support from staff. There is a computer in the home which is used by two residents to play games on or surf the internet. A “Rights checklist” is drawn up for each resident. This includes having keys to the front door and bedroom, privacy, self-advocacy and the right to vote. The daily records showed that some residents go to church or the synagogue. There was evidence in the residents’ daily records of going out to local amenities in the evening to pubs and restaurants, public swimming pools and the cinema, all of which allows the opportunity for social interaction. The residents are supported to maintain links with their families and some go home at weekends. There is guidance for staff about how to support residents’ sexual needs in their care plans. Each resident is supported to choose their own menu, which reflects their preferences. The menus were varied and nutritious, and two residents were on weight reducing diets in accordance with advice from a dietician. I noted that there was fresh fruit available, and residents were having fruit juice or hot drinks at various times during the inspection. One resident told me they were happy with the food provided. Duchess Close 5 & 6 DS0000010425.V333456.R01.S.doc Version 5.2 Page 14 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): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are very good guidelines for staff about how the residents prefer to be supported with their personal care. The health and welfare of the people who live in the home is maintained by access to a full range of healthcare professionals. The procedures for administration of medicines is generally safe, but medication for those residents who self-administer their medication, needs to be stored securely to prevent risks to other residents. EVIDENCE: Some residents require only minimal support with their personal care. As noted above, the residents’ care plans guide staff about how to support the residents in a way they prefer to ensure their wishes are respected. This includes how Duchess Close 5 & 6 DS0000010425.V333456.R01.S.doc Version 5.2 Page 15 they prefer their bath to be run, what time they like to go to bed and what they wear. The two case files I inspected, included good records of healthcare appointments, for example the GP, psychiatrist, psychologist and dentist, which indicated that physical and emotional health care needs are being met. Residents’ weights were monitored monthly, and two residents were on reducing diets. Accident and incidents involving residents were appropriately recorded. The administration of medicines records were inspected and found to be in order with no gaps in staffs’ signatures. However, I noted that the “days of the week” on one blister pack was inaccurate and misleading, which could result in an error being made. The manager immediately corrected this during my inspection. One of the residents is self-medicating and has a drawer in the bedroom for storing medication. However, this drawer was not locked, which could present a risk to the other residents. A requirement is made to address this issue. Duchess Close 5 & 6 DS0000010425.V333456.R01.S.doc Version 5.2 Page 16 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): Both standards were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are cared for in a warm and courteous manner, and complaints about the service are addressed promptly. Not all staff have been trained in the protection of vulnerable adults, which could pose a risk to the welfare of the residents. EVIDENCE: The residents to whom I spoke were satisfied with the service and said they liked the staff who they said, provided good care in meeting their needs. I observed that the staff approached the residents in a caring and courteous manner. The complaints log showed that the majority of the complaints were from neighbours about a particular resident’s behaviour. This relates to the person who is frustrated about not being relocated to more independent living. The manager said that he meets the neighbours and is able to reassure them. The staff that I spoke to, were very knowledgeable about their role in preventing abuse. I was told that a training session on this subject had been Duchess Close 5 & 6 DS0000010425.V333456.R01.S.doc Version 5.2 Page 17 cancelled, which meant that some staff had not yet been trained in this subject. I saw evidence that another session had been booked for June 2007. a requirement is made for all staff to have attended training in Protection of Vulnerable Adults. Duchess Close 5 & 6 DS0000010425.V333456.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): 24, 25 & 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The landlords are not meeting their responsibilities to properly maintain the fabric of the building, which means that the residents are not living in an attractive or comfortable environment. Residents’ bedrooms are decorated in a style that reflects their tastes. The home is clean and tidy and there are good infection control measures in place to protect residents from health hazards. EVIDENCE: Birnbeck Housing Association owns the building and is responsible for the maintenance of the home. Duchess Close 5 & 6 DS0000010425.V333456.R01.S.doc Version 5.2 Page 19 I carried out a tour of the building, including visiting some bedrooms, and identified the following areas that need attention: Both kitchens need to be redecorated and action needs to be taken to repair the hole in the ceiling where an electric cable passes through. The kitchen sinks are damaged and need to be replaced to ensure service users are living in a homely environment. At the last inspection the previous inspector noted that there were several recessed ceiling lights but only one worked in a resident’s bedroom. I was concerned to see that a large number of lights in some areas were not functioning effectively which means that service users are not being provided with lighting that is effective which is not beneficial to their health and wellbeing. The stair carpet is badly worn in places, as is the carpet in the staff office. The sink in one resident’s bedroom has tiles surrounding it that are cracked and these must be replaced. The flooring in one bathroom needs to be replaced, as it is dirty and worn. It was evident from the maintenance request book and e-mails I was shown, that these issues had been brought to the attention of the landlord on numerous occasions but had been ignored. The manager told me that a site visit was booked on the day after the inspection for the landlord to address the problems. In the meantime, requirements are restated in this report for repair and maintenance issues in the home to be rectified. I visited three bedrooms and found that they were adequately furnished and individually decorated to the residents’ tastes. The chests of drawers in two residents’ bedrooms had been replaced since the last inspection. A person is employed to thoroughly clean the home once a week and the staff undertake day-to-day cleaning. At the time of this inspection, the home was very clean and tidy and there were no offensive odours. There is a control of infection procedure and appropriate waste disposal measures in place to prevent health hazards. Duchess Close 5 & 6 DS0000010425.V333456.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): 32, 33 & 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are sufficient numbers of staff on duty to meet the residents’ needs. Staff are trained in appropriate subjects to adequately support the people who live in the home and they receive regular supervision to support them in their work. EVIDENCE: I examined the staff rota, which showed that adequate numbers of staff were available to meet the residents’ needs. The staff on duty matched those on the rota, and all the staff I spoke to, were familiar with the residents and their needs. They also stated that they felt satisfied with the staffing levels. All staff had undergone a written induction to the home and had been trained in health and safety subjects including food hygiene and fire prevention. Duchess Close 5 & 6 DS0000010425.V333456.R01.S.doc Version 5.2 Page 21 Training had also been provided in autism, epilepsy and care planning. Three staff held a National Vocational Qualification at level 2 and one at level 3. No new staff had been employed since the last inspection. There were records to show that all staff receive regular formal supervision and an annual appraisal. The staff I spoke to, said that supervision was important to them because they could express training needs and discuss aspects of their work with the manager. Duchess Close 5 & 6 DS0000010425.V333456.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): 37, 38, 39, 41 & 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live in the home benefit from having a competent manager who provides clear leadership and runs the service efficiently. Good records are maintained to ensure that residents’ finances are well managed and accounted for. Residents and staff are involved in the running of the home and they are protected by good health and safety procedures. EVIDENCE: Duchess Close 5 & 6 DS0000010425.V333456.R01.S.doc Version 5.2 Page 23 The current manager has been in post for almost two years and was transferred from another Adepta home. He has long experience of working with this client group and is an accredited trainer in “SCIP”, (Crisis intervention and prevention). He has just completed his training for NVQ Level 4 in care management and was waiting for final assessment. The staff and residents to whom I spoke, expressed strong confidence in the manager’s ability and his efficient style of running the home. The staff said that their morale was very good and they worked together well. This was confirmed by my own observation that there was a relaxed and friendly atmosphere in the home. Staff meetings are held monthly and there is a weekly meeting for residents, where staff and residents are able to express their views and suggest improvements to the service. I examined the petty cash and the finance records of one resident. There were receipts retained for all purchases, which balanced with the remaining cash held. There were records of weekly fire alarm tests and regular fire drills being carried out. Visitors to the home have to ring the bell and the exits are protected by a coded security system. Regular health and safety audits are carried out and cleaning materials and other hazardous substances were stored securely. Duchess Close 5 & 6 DS0000010425.V333456.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 3 2 3 3 3 4 X 5 3 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 1 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 X 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 3 3 3 LIFESTYLES Standard No Score 11 4 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 x 3 3 3 X 3 3 X Duchess Close 5 & 6 DS0000010425.V333456.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 YA20 YA23 Regulation 13(2) 13 (6) Requirement All medication that is selfadministered must be kept locked when not in use. All staff must attend training in the protection of vulnerable adults. This requirement has been restated from the previous inspection. The previous timescale of 31/07/07 had not been reached. Timescale for action 30/06/07 31/08/07 3. YA24 23(2)(b)(d) Both of the kitchens must be redecorated, the hole in the kitchen ceiling repaired and the kitchen sinks replaced. These requirements have been restated from previous inspections. The timescale of 25/05/07 had not yet been reached. 31/08/07 4. YA24 23 (2) (b) The Registered Person must 31/07/07 ensure that a professionally qualified person investigates the effectiveness of the lights in the home and sends their report along with the action that has DS0000010425.V333456.R01.S.doc Version 5.2 Page 26 Duchess Close 5 & 6 been taken to the local CSCI area office. This requirement has been restated from the last inspection. The timescale of 25/05/07 had not yet been reached. 5. YA24 23 (2) (b) The Registered Person must ensure that the carpet in both the office and on the hall stairs is replaced. This requirement has been restated from the previous inspection. The previous timescale was 10/05/07. 6. YA24 23 (j) The Registered Person must ensure that the identified resident’s bathroom sink tiles are replaced. This requirement has been restated from the previous inspection. The previous timescale was 10/05/07. 7. YA24 23 (b) The Registered Person must ensure that the flooring in the identified toilet is replaced. This requirement has been restated from the last inspection. The timescale of 01/06/07 had not yet been reached. 31/07/07 31/07/07 31/08/07 Duchess Close 5 & 6 DS0000010425.V333456.R01.S.doc Version 5.2 Page 27 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 Duchess Close 5 & 6 DS0000010425.V333456.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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. 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