Inspection on 03/10/05 for Granville Road 75-77

This inspection was carried out on 3rd October 2005.

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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Granville Road 75-77 14/07/08

Granville Road 75-77 31/07/07

Granville Road 75-77 18/04/06

Granville Road 75-77 27/04/05

Granville Road 75-77 25/09/04

Granville Road 75-77 29/04/04

Granville Road 75-77 17/11/03

Granville Road 75-77 13/08/03

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

CARE HOME ADULTS 18-65 Granville Road 75-77 Wood Green London N22 5LP Lead Inspector Susan Shamash Unannounced Inspection 3rd October 2005 11.30 Granville Road 75-77 DS0000010723.V252856.R02.S.doc Version 5.0 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 Granville Road 75-77 DS0000010723.V252856.R02.S.doc Version 5.0 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. Granville Road 75-77 DS0000010723.V252856.R02.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Granville Road 75-77 Address Wood Green London N22 5LP 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 8888 4189 020 8888 4189 HAIL (Haringey Association for Independent Living Limited) Omosanya Majekodunmi Otubanjo Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Granville Road 75-77 DS0000010723.V252856.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th April 2005 Brief Description of the Service: 75 – 77 Granville Road is a registered care home providing personal care for six younger adults with learning disabilities. Circle 33 Housing Association owns the property and the care and support are provided by Haringey Association for Independent Living (HAIL), an independent sector provider offering a range of accommodation for people with a learning disability in the London Borough of Haringey. The home is a large converted domestic premises with three floors. The ground floor comprises the main communal areas and one service user bedroom. The second and third floors contain the remaining service user bedrooms with an additional activity/ therapy room recently created on the second floor. There are adequate bath and toilet facilities in close proximity to the service users bedrooms. The home is situated in a quiet residential road within easy reach of Wood Green shopping centre and a range of multi cultural resources in the vicinity. The stated aim of the home is to provide twenty-four hour support and care for six people with a learning disability to live as independently as possible within the community of Wood Green. Granville Road 75-77 DS0000010723.V252856.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over approximately six and a half hours and was carried out as a routine unannounced visit to the home. Since the previous inspection, the manager had left, and a new manager (Louisa Awobiyi) was visiting the home (as the first day of her induction) on the day of this inspection. The inspector received assistance from the deputy manager, who was available within the home throughout the inspection. The inspector also had the opportunity to speak to another four staff members independently and one service user. The inspector spent some individual time with five other (less verbal) residents. A tour of the premises took place and care records were inspected. What the service does well: What has improved since the last inspection? The inspector was pleased to note that major improvements had been maintained to the home’s building, since refurbishment prior to the last inspection. Bathrooms continued to look bright and inviting, and bedrooms Granville Road 75-77 DS0000010723.V252856.R02.S.doc Version 5.0 Page 6 were generally in a good state of repair. The standard of cleanliness had also improved considerably. Care plans were filled out in detail and had been reviewed within the last six months as required at the last inspection. The sleeping-in room for staff at the home had been re-carpeted and painted as required. Finally provision of hot water to the home had improved so that it was available consistently as appropriate. What they could do better: Further risk assessments must be undertaken for residents to ensure their safety, and all risk assessments must be reviewed at least six-monthly. Prescribed creams should not be stored in residents’ rooms unless a full risk assessment has been carried out, to ensure that risks to all residents are minimised. The complaints book for the home must be updated to include more detail including people involved in the complaint, timescales for action and feedback to the person who complained. A number of minor maintenance issues within the home must be addressed to ensure the comfort of residents. Soft furnishings must be provided in the therapy room at the home so that residents can use it comfortably. It is recommended that a new mattress be provided in the staff sleeping-in room and that measures be taken to ensure the comfort of the resident who prefers to sleep with their head against their bedroom wall. Staff records must be maintained at the home for all new staff and as-andwhen staff in order to evidence that a satisfactory recruitment procedure is in place, protecting residents. The number of staff working on each shift at the home should also be reviewed to ensure that residents have sufficient opportunities to go out in the community when they wish to. Reports of unannounced visits to the home by the responsible individual must be sent to the CSCI on a monthly basis to ensure that standards of care at the home are maintained adequately. Granville Road 75-77 DS0000010723.V252856.R02.S.doc Version 5.0 Page 7 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. Granville Road 75-77 DS0000010723.V252856.R02.S.doc Version 5.0 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 Granville Road 75-77 DS0000010723.V252856.R02.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 New service users are only admitted following detailed assessments, and thus the home is able to meet the needs of all service users in the home effectively. EVIDENCE: As noted at the previous inspection, significant information is available to prospective service users in a video and pictorial format. There had been no changes to the service users living in the home since the previous inspection. Records maintained within service user files showed that their needs had been assessed comprehensively prior to admission. There was also evidence that their needs were being reassessed on a regular basis. Inspection of service user plans and observation of support provided to service users within the home indicated that their needs were being met effectively. Granville Road 75-77 DS0000010723.V252856.R02.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Service users’ needs, choices and aspirations are generally assessed and monitored sufficiently to ensure that these can be met effectively. However there is still room for improvement in the way the home addresses their changing needs within risk assessments to ensure that support provided is responsive. Mechanisms are in place to ensure that service users are involved in the running of the home and that they are encouraged to be as independent as possible, in accordance with their wishes. EVIDENCE: Service users had satisfactory individual plans, and a computerised recording system continues to be used by all staff members with regard to shift support plans. A new format had been introduced to produce a life story book for each service user, alongside person centred planning books and reviews. As required at the previous inspection all service users’ plans had been reviewed and updated within the last six months. Granville Road 75-77 DS0000010723.V252856.R02.S.doc Version 5.0 Page 11 Whilst a number of written risk assessments were available for all service users, and additional risk assessments had been recorded since the previous inspection, discussion with the deputy manager and staff regarding service users’ individual needs indicated that these still did not cover all specific risks for which preventative action was being taken (e.g. a service user who frequently damages property in the building, and a service user who currently keeps a prescribed topical cream in their room). The requirement made at the previous inspection regarding risk assessments is therefore restated. Minutes of service user meetings indicated that they were encouraged to participate in making decisions about the home, including holiday destinations and food to be available on the menu. Observation of staff/service user interactions also indicated that they were encouraged to be involved in household routines, thus practicing independent living skills, and that their choices were respected. Granville Road 75-77 DS0000010723.V252856.R02.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 17. Service users have a wide range of opportunities to take part in age, peer and culturally appropriate activities. Appropriate activities are available within and outside of the home, and support is provided in developing independence skills. The home has a creative and innovative in supporting service users with educational, vocational and leisure activities. However occasionally inadequate staffing numbers may minimise opportunities for service users to go out in the local community. Service users appear to be involved in and satisfied with the provision of food at the home, which consists of a varied and nutritious diet that takes account of cultural preferences. EVIDENCE: Granville Road 75-77 DS0000010723.V252856.R02.S.doc Version 5.0 Page 13 Service users’ activity charts, care plans and daily notes indicated that a wide range of activities were available to service users both within and outside of the home. Various games and jigsaw puzzles were available in the home, in addition to a recently refurbished therapy room equipped with a wide selection of multisensory equipment. All of the service users were attending day activities during the early part of the inspection, at various day centres within the local area. Activities at these centres included music, arts and crafts and swimming. One service user is attending an access to further education course for people with profound and complex learning difficulties at a local college. Each service user had a weekly rota of chosen activities within their service user plan. The manager advised that no service users have jobs or are involved in employment related programmes, however one staff member had previously arranged for and supported a service user, who expressed an interest in becoming a nurse, to have a day’s work experience in a residential care home for older people, which had been a huge success. The Turkish speaking staff member who had supported the Turkish speaking service user for some time, had left since the previous inspection. However the deputy manager advised that a new Turkish speaking staff member was due to commence work at the home shortly and would be key working this service user, to ensure that their needs were met. In addition all members of the staff team had learned rudimentary words in Turkish. Staff continue to support one service user in attending a Hare Krishna temple and a Hindu temple periodically, but no other service users choose to attend a place of worship on a regular basis. There was evidence within service user plans, and though observation of the evening routines in the home, that service users were encouraged to be involved in the day-to-day tasks of shared home living. Service users spoken to had enjoyed a trip to Hastings in July. Staff and service users told the inspector that trips were arranged within the local community to visit restaurants, the pub and local shopping facilities, however these were dependent on their being sufficient staff on duty in the home. A requirement is made under Standards 33 and 34 accordingly. Menus seen were appropriate and indicated a range of balanced meals. Food was appropriately stored and in date, and the kitchen was clean and tidy. Service users spoken to indicated that they enjoyed the food served within the home. Granville Road 75-77 DS0000010723.V252856.R02.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Service users receive appropriate physical and emotional support, and are generally adequately protected by systems in place for administering medicines. However risk assessments are required regarding the storage of prescribed creams for topical application to ensure the safety of all service users. EVIDENCE: Service user files inspected showed regular input from a variety of health professionals. These included psychiatry, psychology, speech and language therapists as well as appointments with G.P.’s and dentists. Written feedback from one healthcare professional indicated that the home was supporting service users’ healthcare needs appropriately. The inspector spoke to several staff members and observed the interactions of staff and service users prior to the early evening meal in the home. Staff were seen to act appropriately and sensitively with service users treating them with dignity and encouraging them to be independent where possible and providing support where needed. In conversation, staff spoke enthusiastically about their work, and were well informed and skilled in working with service users with profound learning difficulties. Staff were also seen to knock and wait for an answer prior to entering service users rooms, toilets and bathrooms as appropriate. Granville Road 75-77 DS0000010723.V252856.R02.S.doc Version 5.0 Page 15 Service users current medication and MAR charts were inspected and appeared to be complete and dispensed satisfactorily. As noted at the previous inspection, all staff administering medication within the home had undertaken appropriate training in August 2004. However the inspector was concerned to observe that a prescribed cream for topical application was being stored in a service user’s room, without a risk assessment having been undertaken regarding possible safety concerns for the service user and other service users at the home. A requirement is made accordingly. Granville Road 75-77 DS0000010723.V252856.R02.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Whilst there is evidence that service user’s views are acted upon, inadequate recording of complaints at the home means that it is not possible to determine whether they are addressed appropriately within the timescales set. Service users are well protected from abuse and self-harm, as appropriate, with staff very aware of the need to monitor changes in the behaviour of service users who are non-verbal, and thus particularly vulnerable. EVIDENCE: The home has a satisfactory complaints policy, however the complaints record maintained at the home is not sufficiently detailed to determine actions taken, who was involved and timescales by which the complaint was investigated and feedback provided to the complainant. A requirement is made accordingly. Care plans and service user meeting minutes indicated that service users views are listened to. Discussion with staff members and observation of procedures within the home, indicated that staff were familiar with the adult protection policy for the home and that records were maintained as required. Granville Road 75-77 DS0000010723.V252856.R02.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 28 and 30. The environment in which service users live is bright, comfortable and safe. The home is commended for innovative refurbishment of a spare room into a therapy room, however lack of soft furnishings in this room mean that it is not yet a comfortable environment for service users. The home is maintained to a satisfactory level of cleanliness, however a small number of maintenance issues must be addressed to ensure the comfort of service users and staff. EVIDENCE: Service users live in an environment that appears to meet their needs with personalised rooms and sufficient toilets and bathrooms. All service users’ rooms were inspected and found to be furnished and decorated appropriately. It is recommended that a solution be sought to ensure the comfort of the service user who rests their head against their bedroom wall when lying in bed e.g. provision of padding against the wall. Granville Road 75-77 DS0000010723.V252856.R02.S.doc Version 5.0 Page 18 At the previous inspection the inspector was impressed at the transformation of the bathrooms on the first and ground floor following refurbishment, including stencilled designs on the walls. These rooms continue to look bright and welcoming, however a hole in the wall caused by the door handle and a railing pulled away from the wall in the ground floor bathroom must be repaired, alongside a hole in the wall near the bath in the first floor bathroom. The medication cupboard on the ground floor also needs repainting. At the previous inspection an empty room on the top floor of the home had been refurbished into a therapy room for service users. It includes vivid murals on the walls, painted by staff, and a wide range of multi-sensory equipment. However soft furnishings have still not been provided in this room, and this compromises service users’ comfort. As required at the previous inspection the carpet in the sleeping-in room was replaced, and the room had been painted. However staff told the inspector, and the inspector observed that the mattress in this room was not comfortable. It is also recommended that this be addressed. At the previous inspection it was noted that there was an intermittent problem with adequate hot water availability in the home for several months. This issue had been addressed as required, and temperature records indicated that no further problems were being experienced with the home’s supply of hot water. Granville Road 75-77 DS0000010723.V252856.R02.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36. Whilst it appears that service users are generally protected by a robust recruitment procedure, insufficient documentation retained in the home for new and as-and-when staff means that the inspector cannot be certain that the procedure is followed in all cases. Service users are supported by staff who are experienced and receive appropriate training and supervision to meet their needs. However sufficient staff are not always available to ensure that service users can make full use of community facilities, particularly in the evenings. EVIDENCE: The home generally has an effective recruitment policy and the majority of staff files inspected included all information specified under the care homes regulations. However an enhanced CRB disclosure was not available for the most recently employed staff member and staff files were not available for asand-when staff employed at the home. This requirement made at the previous inspection is therefore restated. Inspection of staff files and discussion with five staff members indicated that service users are supported by an effective and competent staff team, who have attended a wide range of training courses. Regular supervision sessions are arranged to support staff as appropriate. Granville Road 75-77 DS0000010723.V252856.R02.S.doc Version 5.0 Page 20 However observation of the staff rota and discussion with staff also indicated that there were times when only staff members were on duty (particularly in the evening) so that there were not sufficient staff to take service users out into the community if they so wished. As required at the previous inspection, the number of staff members scheduled to work in the home at all times, must be reviewed, with particular consideration given to service users’ needs for attending community activities. Granville Road 75-77 DS0000010723.V252856.R02.S.doc Version 5.0 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. The home is well organised, and a new manager has been appointed. Monitoring systems are in place to safeguard service users’ views are taken into account. However this is compromised by insufficient reports of monthly visits by the responsible individual on behalf of the provider. The health and safety of service users is generally promoted and protected effectively. EVIDENCE: The manager who was in place at the previous inspection, had ceased to work at the home, and a new manager who had just been appointed, was visiting the home on the day of the inspection, as the first day of her induction. As required, an application pack for her to register as manager had been requested from the Central Registration Team. Granville Road 75-77 DS0000010723.V252856.R02.S.doc Version 5.0 Page 22 Two reports had been received since the previous inspection regarding unannounced visits to the home from the responsible individual. However it is required that monthly visits be undertaken to monitor the standards of care in the home adequately. Following the inspection it emerged that monthly visits were being undertaken by the responsible individual, however it remains required that reports of these visits be sent to the home and the local CSCI area office on a monthly basis. Maintenance records and safety certificates were inspected at the previous inspection. However, despite a requirement made that a current satisfactory electrical installation certificate be available for the home, the only certificate on the day of the inspection remained unsatisfactory, requiring action to be taken and repeat testing within six months of 13th May 2005. However following the inspection a subsequent electrical installation certificate was provided for the home dated 1st June 2005, stating that all work outlined in that certificate had been undertaken as required. This issue is therefore found to have been addressed as required. Granville Road 75-77 DS0000010723.V252856.R02.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score 2 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X 3 X 2 X 3 LIFESTYLES Standard No Score 11 X 12 3 13 2 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 2 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Granville Road 75-77 Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X 3 X DS0000010723.V252856.R02.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? YES 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 YA9 Regulation 13(4)(b) 14(1)(a)(2)(a) Requirement Timescale for action 25/11/05 2 YA20 13(2) 3 YA22 17(4) Sched 4(11) 22 The registered person must ensure that further risk assessments are undertaken for service users so that all preventative action taken to avoid risks is recorded, and that these are reviewed at least six-monthly. (Previous timescale of 24/06/05). The registered person must 11/11/05 ensure that risk assessments are undertaken prior to prescribed medication (e.g. creams for topical application) being stored in any service user’s room. The registered person must 18/11/05 ensure that the home’s record of complaints includes details of all persons involved in the complaint, action taken and timescales by which the complaint is notified of the result of the complaint investigation. (Previous timescale of 13/05/05 not met). This requirement is restated and Version 5.0 Page 25 Granville Road 75-77 DS0000010723.V252856.R02.S.doc amended. 4 YA24 23(2)(d) The registered person must ensure that the ground floor bathroom, hole in the wall caused by the door handle, and the handrail is repaired, alongside the first floor bathroom hole in the wall (by the bath). The medication cupboard should be repainted. The registered person must ensure that soft furnishings are provided in the therapy room for service users’ use. The registered person must ensure that staffing numbers within the home are reviewed with regard to providing sufficient staff so that service users’ needs for attending community activities are taken into consideration. The registered person must ensure that records as specified in 17(2) Schedule 4(6) of the Care Homes Regulations 2001 are available for inspection for all new staff members and all as-and-when workers employed at the home. (Previous timescale of 10/06/05) not met. This information was provided within the timescale set as required. A copy of the Criminal Records Bureau (CRB) disclosure that was not available for the staff member identified, and regular bank workers at the home, should be sent to the local CSCI area office. Granville Road 75-77 DS0000010723.V252856.R02.S.doc Version 5.0 Page 26 02/12/05 5 YA27 23(2)(h) 16/12/05 6 YA33 18(1)(a) 16/12/05 7 YA34 17(2) Sched 4(6) 18/11/05 8 YA39 26 The registered person must ensure that reports of unannounced responsible individual visits to the home are sent to the home and the CSCI local area office every month. 02/12/05 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 Refer to Standard YA24 YA26 Good Practice Recommendations It is recommended that a new mattress be provided in the staff sleeping-in room. It is recommended that a solution be sought to ensure the comfort of the service user who rests their head against their bedroom wall when lying in bed e.g. provision of padding against the wall. Granville Road 75-77 DS0000010723.V252856.R02.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Granville Road 75-77 DS0000010723.V252856.R02.S.doc Version 5.0 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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