Inspection on 08/08/07 for Greenacres

This inspection was carried out on 8th August 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Greenacres 07/08/08

Greenacres 21/11/06

Greenacres 05/12/05

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Pinta

Kestrel House, St Anne`s Opportunity Centre,

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

CARE HOME ADULTS 18-65 Greenacres 67 Delapre Drive Banbury Oxfordshire OX16 3WS Lead Inspector Delia Styles Unannounced Inspection 8th August 2007 14:30 Greenacres DS0000065398.V344532.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 Greenacres DS0000065398.V344532.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. Greenacres DS0000065398.V344532.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Greenacres Address 67 Delapre Drive Banbury Oxfordshire OX16 3WS 01295 269535 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) haroon@caretech-uk.com CareTech Community Services (No.2) Ltd Mrs Deborah Jill Bleach Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Greenacres DS0000065398.V344532.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st November 2006 Brief Description of the Service: Greenacres is a detached family house situated in a quiet residential area of Banbury within walking distance of local facilities. It is registered for up to four people with learning disabilities. Some parts of the home have been adapted for wheelchair access. The home is run and managed by CareTech Community Services Ltd, an organisation with experience in providing services for people with learning disabilities. The fees for this home range from £1,155.92 to £1,835.78 per week. Greenacres DS0000065398.V344532.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection of the service was an unannounced ‘Key Inspection’. The inspector arrived at the service at 2.30 pm on Wednesday 8th August and was in the home for almost 3 hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who live here, and those of the manager and staff seen during the inspection. The inspector spoke with three members of staff on duty; one carer acting as shift leader and two agency staff members. The inspector toured the home, and looked at residents’ care plans and other records kept in the home. The manager was visiting the Head office and was not at the home during much of the inspection, but returned late afternoon and was available to discuss how the home was doing and received feedback from the inspector at the end of the afternoon. Comment cards from relatives and visiting health care professionals were not received in time for inclusion in the report on this occasion. Comments and opinions received after publication of the report will contribute to the next inspection process. The inspector would like to thank the residents and the manager and her staff team for their assistance with the inspection. What the service does well: The home meets the very different needs of the 3 people living in the home. There is a good range of activities for residents to be involved in, both in the house and in the wider community. The people who live here are actively involved in the way the home is run, and the staff are good at making sure residents’ wishes and individual choices about their care and how they spend their time are carried out. The home is comfortable and clean. Residents choose how they decorate and furnish their rooms. Residents’ care is given by staff members and visiting health and social care professionals who know and respect the individual residents and their needs. Greenacres DS0000065398.V344532.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. Greenacres DS0000065398.V344532.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 Greenacres DS0000065398.V344532.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): Standard 2 could not be fully assessed. There have been no new admissions to the home since the last inspection so that the revised assessment and admission procedures of the home have not been tested. EVIDENCE: At the time of this inspection the home had a vacancy for one resident. The providers’ Annual Quality Assurance Assessment (AQAA)) states that the preadmission assessment of potential new residents has been reviewed and amended since the last inspection. There have been no new admissions since the last inspection to test this new assessment procedure. Greenacres DS0000065398.V344532.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. The care documentation system has improved since the last inspection. People who live here know their assessed and changing needs and personal goals are reflected in their individual Plan. Residents’ individuality and independence are supported and documented and they are able to take risks as part of an independent lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All three residents individual plans were viewed. The manager had explained the changes made to improve these records of care in the annual quality assurance assessment (AQAA) submitted to the commission. Residents are consulted on and participate in all aspects of the home with staff assistance as needed. The records show that ‘talk time’ – weekly formal or informal discussions with each individual – includes asking residents about what activities they would like, how they feel about their relationships with other people living here and with staff. An action plan is developed from talk time and the follow up or outcomes are recorded. Greenacres DS0000065398.V344532.R01.S.doc Version 5.2 Page 10 One resident’s physical health care needs have altered considerably over the past 12 months. Staff have adapted the way in which they communicate with and help this person with activities, using photographs and sensory sessions. There is no ground floor room vacant and the home has no lift; the resident is not able to leave their first floor room because of their physical frailty. There was evidence that the health care and wellbeing of this individual are reviewed and discussed regularly with health and social care professionals. Additional aids and equipment – a pressure-relieving mattress and hoist – have been provided to assist staff with the physical care of this resident. There are 6-monthly and annual reviews of residents’ care that include getting the views of the individual residents and their relatives and representatives. Records seen by the inspector showed that residents’ individual support requirements had been reviewed recently. The home has a system for identifying and assessing risk for residents during everyday activities. These had been reviewed, signed and dated by staff. From the evidence seen, the inspector considers that Greenacres would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. Greenacres DS0000065398.V344532.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. Residents make choices about their life style and are supported to develop their life skills. Links with the local community and facilities give residents a varied choice of leisure activities that enrich their social and educational opportunities. Overall, the dietary needs of residents are satisfactorily met and the selection of food meets residents’ tastes and choices but the nutritional content of menu choices on offer should be improved by including more fresh produce. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The age range and care needs of the current residents are varied and it was evident to the inspector that the home tailors individual activities to meet the individual’s preferences and explores age appropriate opportunities for social and educational experiences for each person. On the day of the inspection the inspector was in the home during the afternoon. One resident was able to communicate clearly with the inspector. They told her about the different things they do during the day at college, friendships made with other people there and at other club meetings, and trips Greenacres DS0000065398.V344532.R01.S.doc Version 5.2 Page 12 out with their family. This individual was looking forward to having a holiday with family. The same resident has a pet hamster in their room and contributes to its care. The home also has a pet cat. The other two residents were not able to communicate, but with the help of staff and notes seen during the inspection, the inspector got an idea about things they like to do. The opportunities provided in-house for another individual are less structured; for example, drawing, painting, reading, music sessions, watching TV and DVDs with occasional meals out, cinema, bowling, pub and other outings in the local community. The resident who is less well has frequent staff attention who offer appropriate indoor activities for short periods of time – such as use of sensory items and video cartoon films. There is an activity board in the dining room that is changed every week with residents’ help and that shows the choice of activities inside and outside the home. Residents’ care records include pictures and photos describing the activities they most like and those that they least enjoy. Service users’ views about the home were not requested by the inspector in the form of comment cards on this occasion. Contact details for their relatives were not provided by the home in time for their survey questionnaires to be returned for inclusion in this report. However, the inspector considers that the recent ‘talk time’ and review meeting records that include the views of residents and their relatives and representatives, provide evidence of positive feedback about the home. Over the last 12 months, the manager reports in the AQAA that the relationship between the home and neighbours living nearby has greatly improved. The manager confirmed this with the inspector and said she regularly visits a neighbouring householder in person to check that they have no concerns or complaints to make. The inspector looked at the menus for the week that were displayed in the kitchen. The choices included a relatively high proportion of convenience and processed foods. The inspector recommends that the menus are reviewed to include more fresh vegetables and fruit to improve the nutritional value of the choices on offer to residents. One resident has prescribed nutritional supplement meals to improve their diet. On the evening of the inspection, one resident was being assisted by a staff member to choose from a menu from a local take-away meal service. Greenacres DS0000065398.V344532.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. The health and personal care of the people who live here are met in a way that supports their dignity and privacy. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Essential information needed by staff to be able to provide personal and health care support was included in residents’ files. The manager said that all staff have had specific advice and training from the Learning disability Team about caring for the resident whose health has declined over the last 6 months: training includes care of people with dementia, skin care (to prevent pressure ‘sores’/ulcers), sensory sessions and use of the hoist when transferring the person from bed to a chair and the bathroom. A physiotherapist and district nurse and doctors have been involved in assessing and reviewing the care needs of this individual. One resident uses a wheelchair and some adaptations have been made to the home to make it more accessible for this person. An electric wheelchair that has been provided for this person is not suitable for use up and down kerbs outside but can be used when they are out at college. The manager said that further efforts are being made to obtain a more suitable wheelchair. Residents’ medicines are securely kept in a locked medicines cabinet. The home uses a pharmacist produced medication administration record (MAR). Greenacres DS0000065398.V344532.R01.S.doc Version 5.2 Page 14 These were checked by the inspector and were up to date and correctly completed. Records showed that all staff received training in safe handling of medicines that meets the required training standard. All care staff have been assessed as competent to administer residents’ medicines. Greenacres DS0000065398.V344532.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. People who use the service are actively assisted to express their views and the staff listen to, and act upon these. Residents have access to an effective complaints procedure, are protected from abuse and have their rights protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents have weekly ‘talk time’ that helps them to share their views and any concerns with staff. No complainant has contacted the Commission with information concerning any complaint made to the service since the last inspection. The manager said that no complaints have been received directly by the home in the last 12 months. She plans to improve communication of any concerns with residents by use of pictures and symbols to make the procedure easier to understand. All staff have received training in adult safeguarding and the Oxfordshire multiagency Code of Practice is available and accessible to all the staff. The manager said that all staff, including agency staff, have copies of the code of practice. Regular residents’ reviews, contact with outside agencies and organizations, regular visits to the home by health and social care professionals and visits by senior managers from the provider organization, CareTech, provide the opportunity for monitoring of the standards of care and safeguarding of the people who live here. Greenacres DS0000065398.V344532.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is adequate. The décor and furnishings in most areas of the home have been improved since the last inspection and residents have a clean and comfortable environment to live in. The kitchen facilities are unsatisfactory and must be improved to make them safe for service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector toured the building. Recent investment has significantly improved the environment of this home. Since the last inspection, the house has been re-carpeted and redecorated throughout. One resident has been involved in choosing the colours and furnishing for their room. New furniture has been purchased. Secondary glazing to one resident’s room window and another window on the first floor have been replaced A coffee table in the lounge is damaged and should be repaired or replaced. The kitchen is in urgent need of refurbishment and replacement of some equipment. This was pointed out at the last inspection and there has been further wear and deterioration of cupboard doors and work surfaces since then. Staff said that the kitchen sink leaks. The manager said that the work is Greenacres DS0000065398.V344532.R01.S.doc Version 5.2 Page 17 budgeted for and it is planned should be completed in the next 12 months. A requirement is made to prioritise the kitchen refurbishment to provide safe and adequate equipment and fittings for residents and staff to use for the preparation and storage of residents’ meals. The garden at the rear of the home has been tidied and cleared providing a good-sized area of lawn and garden seating for residents to use. One resident enjoyed sitting out in the sunshine with staff during the afternoon of the inspection. Another resident had chosen to play football with staff. The home now has gardeners to regularly maintain the garden, which has improved the appearance and access for residents and staff. Overall, the home was clean and bright and comfortable. Staff have protective clothing to wear whilst helping residents with personal care. All staff are due to attend training on the prevention and control of infection in September. Greenacres DS0000065398.V344532.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is adequate. After a period of considerable instability in staffing there is now an improving staff situation and better continuity of care and support for the people who live in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector talked to three staff on duty during the afternoon of the inspection – one permanent and 2 agency staff. The permanent staff member was shift leader. Both agency staff have worked in the home for some time and said that they had got to know the residents and their care needs well. Staff photos and names were displayed on a board in the dining room. Staff were clear about their roles and responsibilities towards residents. The permanent staff member has worked at the home for 3 months but did not appear to be aware of the role of the commission, or the national minimum standards for care homes for adults, though the commission’s inspection reports and information about the commission were on display in the office. In the home’s AQAA document, the manager said that the staffing situation in the home has improved since the last inspection. Though 6 full time staff have left the home in the last 12-month period, the manager said that recruitment had been successful and just one staff vacancy remained to be filled. The Greenacres DS0000065398.V344532.R01.S.doc Version 5.2 Page 19 manager hopes to recruit a deputy manager. The manager reported that the recent change to having a waking member of staff on duty overnight had proved beneficial for the residents. There are currently 7 full time staff members but the home still relies on agency staff - a total of 2,137.75 hours had been worked by agency staff for the period April to June 2007. However, the same agency staff are supplied and this has improved continuity of care for residents. The organisation has a well-structured training programme for all care staff and staff training records seen by the inspector verified that staff are supported and encouraged to attend training relevant to their work. The manager stated in the AQAA information that new staff are supported through their induction training period which includes using the Learning Disability Award Framework (LDAF)-accredited induction training, and foundation training that is completed within 6 months. The inspector viewed staff files for three permanent staff sampled at random. These were well organised and contained the necessary documentation. None of the current permanent staff have achieved the National Vocational Qualification in care Level 2 or above so the home has not met national targets to have 50 of staff qualified. One staff member is working towards the NVQ Level 2 qualification. The home plans to increase the number of staff who undertake NVQ training. Greenacres DS0000065398.V344532.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is adequate. Overall, the home is managed in ways that focus on the rights, best interests and wellbeing of the people who live here. The fire authority must be consulted about the adequacy of the policies and practices in relation to containing fire and protecting escape routes to reduce the risks for residents and staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It is expected that the registered manager shall undertake further training qualifications at level 4 NVQ in both management and care. Therefore, this standard is rated as ‘standard almost met’ scored 2. The registered manager is currently undertaking the Registered Managers Award. In the home’s AQAA document, the manager reports that she has continued to develop her managerial skills with the support of her line manager in the organisation, and that the staff team is now working well together in the best interests of the people who live here. Greenacres DS0000065398.V344532.R01.S.doc Version 5.2 Page 21 The inspector’s observation of interaction between the manager, staff and residents confirmed that residents are treated with kindness and respect and encouraged to be involved in day-to-day decisions about how the home is run. The home, generally, has sound policies and procedures in line with current legislation and practice. Efficient systems are in place to monitor staff adherence to policies and procedures during their practice. The home works to a clear health and safety policy and checks take place to ensure the home meets relevant health and safety requirements and legislation. The office is well organised and tidy with files and documents required for the running and organisation of the home accessible and up to date. A random check of the fire safety logbook showed that the fire safety checks were up to date. However, the inspector brought some issues of concern relating to fire safety to the attention of the manager. These included the inspector’s observation that door wedges were holding one resident’s room, and the staff ground floor office doors open; and that the room door of another resident had a scarf tied around the handle (the inspector was told that this is to stop the door banging at night). In the event of a fire the open doors and door that could not fully close, would not prevent or slow the spread of flames and smoke. Also the plans in place for the evacuation of residents from the first floor in the event of a fire, in particular for the person who is now physically dependent, should be reviewed to ensure that the arrangements for the evacuation of residents and/or containment of fire are agreed as satisfactory by the fire and rescue service. The fire officer must be consulted and advice sought about the fire safety precautions in place in the home. Greenacres DS0000065398.V344532.R01.S.doc Version 5.2 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 X 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 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X X X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 2 X Greenacres DS0000065398.V344532.R01.S.doc Version 5.2 Page 23 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 YA24 Regulation 16:(g) (h) Requirement Provide suitable, safe kitchen equipment and facilities for the preparation and storage of food and ensure that such facilities are safe for use by service users. Consult with the fire authority and ensure there are adequate arrangements in place for containing fires and for the evacuation of all persons in the care home, in the event of fire. Timescale for action 30/11/07 2. YA42 23: (4) (b) and (c) (i) (iii) 30/11/07 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 YA17 YA24 Good Practice Recommendations Review the menus in consultation with residents and staff to ensure that there is sufficient variety and fresh fruit and vegetables included in the choices available. Repair or replace the broken coffee table in the lounge. Greenacres DS0000065398.V344532.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Greenacres DS0000065398.V344532.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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