Inspection on 07/06/07 for Hardy Drive (23)

This inspection was carried out on 7th June 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hardy Drive (23) 10/07/06

Hardy Drive (23) 06/01/06

Hardy Drive (23) 06/09/05

Hardy Drive (23) 21/02/05

Hardy Drive (23) 16/08/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Hardy Drive (23) 23 Hardy Drive Royston Hertfordshire SG8 5LZ Lead Inspector Mrs Sheila Knopp Unannounced Inspection 7 & 12th June 2007 15:40 th Hardy Drive (23) DS0000019404.V338533.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 Hardy Drive (23) DS0000019404.V338533.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. Hardy Drive (23) DS0000019404.V338533.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hardy Drive (23) Address 23 Hardy Drive Royston Hertfordshire SG8 5LZ 01763 243 684 01763 245 972 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) www.mencap.org.uk Royal Mencap Society Diane Elizabeth Evans Care Home 6 Category(ies) of Learning disability (6), Physical disability (1) registration, with number of places Hardy Drive (23) DS0000019404.V338533.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home may accommodate up to 1 place for a person with physical disability associated with learning disability. 10th July 2006 Date of last inspection Brief Description of the Service: Hardy Drive is a small home, which accommodates six service users who have learning difficulties, one of whom may have a related physical disability. The home is situated on a housing estate in Royston and blends in with the local housing. It offers a large lounge, conservatory, kitchen/dining room, and relaxation/sensory room on the ground floor. One bedroom with en-suite is on the ground floor, which accommodates one service user with a physical disability. There is a chair lift providing access to the first floor for some one with a physical disability. The first floor contains five further bedrooms, a bathroom, shower room and the staff office/sleep-in room. A large garden to the rear of the house offers a relaxing area for service users to enjoy in nice weather. Aldwyck Housing owns the building and is responsible for maintenance. The care service is provided by Mencap. Information about the service provided at 23 Hardy Drive, including the most recent inspection report can be obtained on request from the manager. Each person living at Hardy Drive has a tenancy agreement that sets out his or her individual contribution towards the rent, which is part of a block contract with Hertfordshire County Council. Individual contributions are currently £62.35 per week. Hardy Drive (23) DS0000019404.V338533.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The information in this report is based on two visits to the service where the inspector met 6 service users and four staff. Survey forms were sent to the 6 service users who live at Hardy Drive, relatives and health & social care professionals who have contact with the service users. At the time of writing this report 6 surveys were returned from service users who had been assisted to complete them by staff at Hardy Drive. The inspector had requested that staff made arrangements for service users to take their forms with them to their daytime activity so that an independent and confidential view could be obtained but this did not happen. Two completed surveys were received from relatives and one health care professional. Information received by the Commission since the last inspection on 10/7/06, which included two referrals made by Mencap under the Hertfordshire Safe Guarding Adult procedure for vulnerable adults, have also been reviewed and considered. What the service does well: This is a small home in a residential area that has provided stability for the service users living there over many years. A health care professional said Hardy Drive provided service users with a ‘good, stable, caring environment’. All six service users who completed survey forms, with the help of staff, confirmed they felt well care for. Staff demonstrated a positive and inclusive approach to supporting the needs of service users. There is a positive approach to enabling service users to lead busy and active lives. The manager produces an excellent newsletter to keep people in touch with what is happening at Hardy Drive. Each service user has their own room, which is decorated and furnished to reflect their individual needs and interests. The lounge and kitchen diner encourage service users and staff to join together for meals or watch television. There are excellent quality assurance systems in place that involve internal and external checks on the service provided to service users. Hardy Drive (23) DS0000019404.V338533.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The manager and Mencap have acted appropriately in referring two incidents of concern under the Hertfordshire Safe Guarding Adult procedure. The information made available to the inspector indicated there had been a satisfactory conclusion to an incident involving factors outside the home but a final report on the outcome of an investigation into an alleged theft of money from four services users in January 2007 has not been completed. This inspection identified that a medication error had not been reported to the Commission as required but appropriate action had been taken to prevent a reoccurrence. The manager needs to review the availability of liquid soap and disposable hand towels to reduce the risk of spreading infection because of poor hand hygiene. To reduce the risk of accidents the manager needs to review the risk assessments for the first floor window restrictors and make the necessary adjustments as the opening distance was greater than that advised under health & safety guidance. One person who completed a survey form, felt staff should always say who they were when answering the telephone. Hardy Drive (23) DS0000019404.V338533.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Hardy Drive (23) DS0000019404.V338533.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hardy Drive (23) DS0000019404.V338533.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2- People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. If the opportunity to live at Hardy Drive became available any new service users would be involved in a thorough assessment process to identify their needs and aspirations. EVIDENCE: There have been no recent admissions to Hardy Drive, which provides a stable home environment for the people who choose to live there. Mencap have comprehensive polices and procedures in place for ensuring the needs of individuals moving into one of their homes can be met. This would include the opportunity to met the other service users and try out the service. Hardy Drive (23) DS0000019404.V338533.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): Standards 6, 7 & 9 - People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Each service user has a person centred care plan that tells staff how they wish to be supported and is kept under review as changes occur. Opportunities are available for service users to make decisions about their own lives and to influence how they home is run. There is a positive and enabling approach to managing risks so individuals can lead fulfilling lives and take part in activities they enjoy. EVIDENCE: Each person has a person centred plan of care based on their views about how they wish to be supported from day to day and longer term goals. Family, advocates and professionals from specialist services are also involved in the assessment process and reviews. The support plans reviewed demonstrated that individual procedures are in place for situations that require staff to Hardy Drive (23) DS0000019404.V338533.R01.S.doc Version 5.2 Page 11 promote positive behaviour and independence in challenging situations. Training in managing and responding to challenging behaviour has led to a more consistent approach among the staff team and a reduction in incidents. A relative confirmed staff are now working to the same guidelines. Service users are involved in making decisions about their lives through the regular assessments and reviews that take place, the allocation of a key worker, service user meetings and regular visits to Hardy Drive by an advocacy worker. Five out of six service users who completed surveys with support from staff confirmed they were involved in making decisions about how their home. The risk assessment format used encourages staff to think positively about the activity or event they are assessing and how it can be achieved. Staff gave examples of their approach to planning events to meet the aspirations of individual service users. Service users are reminded of the steps they must take to ensure their personal safety when out and about in the community. Hardy Drive (23) DS0000019404.V338533.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): Standards 12, 13, 15, 16 & 17 - People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Each service user had a weekly plan of activities and social events that promotes their personal development and interests. Service users are encouraged to keep in contact with their families and be involved in the local community. Service users are involved in the planning, shopping and preparation of meals. EVIDENCE: Each person’s support plan details their preferred daily routine and how this can be achieved, to enable them to go out for their educational and leisure activities during the day as well as attending activities of daily living in the evening and at weekends. Four out of the six service users who completed surveys, with the support of staff, said they liked living at Hardy Drive and there were good activities. Hardy Drive (23) DS0000019404.V338533.R01.S.doc Version 5.2 Page 13 Discussion with service users confirmed arrangements were made for them to stay in touch with family and friends. This includes supporting service users who spend time away from Hardy Drive visiting family for short breaks or longer holidays in this country and abroad. The manager has found that issuing a quarterly newsletter of information and pictures about life at Hardy Drive is a positive way of promoting involvement and keeping people in touch. Service users and staff are aware of the house rules on seeking permission before entering each other’s rooms. Service users picked up their own post when they arrived home. The Hardy Drive cat, fish and budgie, provide a point of interest and caring for the service users. Hardy Drive (23) DS0000019404.V338533.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): Standards 18, 19 & 20 - People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are able to express their individual personalities through the choices they make regarding personal care, clothing and accessories. Service users are able to access local community health services to maintain and promote a healthy lifestyle. Overall there are good systems in place for ensuring service users receive their prescribed medicines safely and appropriate action is taken to address problems that occur The culture and ethos of the service and staff team supporting service users promotes their individuality and dignity. EVIDENCE: The records of four service users were reviewed as part of this inspection. They were up to date and clearly set out how each person wished to be supported. Hardy Drive (23) DS0000019404.V338533.R01.S.doc Version 5.2 Page 15 Each person’s support plan sets out how their personal needs, associated with personal hygiene and specific health care needs, such as seizures or weight loss, are to be met. Service users are able to visit the local surgery, which is a short walk away. Each service user has a health action plan folder providing details of their past and current medical history and how they prefer any required interventions or procedures to be carried out. The records, which, are in written and also in pictorial form, can be taken to hospital and GP appointments to ensure consistent information is available. Overall there are good systems in place for ordering, storing and administering the medication that the service users require. The systems meet the required standards and were found to be satisfactory on the day of inspection. The records indicate staff took appropriate and prompt action to deal with one recent administration error that had occurred. The manager needs to ensure that incidents involving the well-being or safety of service users are reported to the Commission as required under Regulation 37. On the day of inspection service users were encouraged to plan the weekly menu with the assistance of pictures of meal options. Advice and guidance was given on healthy options and preferences. One service user went out shopping with a member of staff. The care records confirmed that the dietary needs of each service user are assessed and dietetic and medical advice obtained as necessary. Five out of six service users who completed survey forms with help from staff said they liked the food. Hardy Drive (23) DS0000019404.V338533.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): Standards 22 & 23 - People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are able to share their views through a variety of informal and formal processes. The overall ethos of the organisation that runs through staff recruitment, training, supervision and the policies and procedures in place should protect service users from harm. However an incident earlier in the year led to service users losing money and a report on the outcome of the internal investigation is not yet available, although proper procedures for checking the security of money have been reinstated. EVIDENCE: Staff demonstrated their awareness of listening to the views of service users as part of their day-to-day contact and key worker role. Service user meetings are held and a simplified version of the complaint process is discussed on a regular basis to remind service users of their rights. Four out of the six service users who completed surveys, with the support of staff, said they knew who to speak to if they were not happy. Individuals also have contact with advocacy workers, family and individuals outside the home, who they meet as part of their daytime activities or professional reviews. Staff receive training, as part of their induction on recognising and responding to signs of abuse. This also covers their responsibilities as social care workers to speak out if necessary and the protection afforded to them under Mencap’s Hardy Drive (23) DS0000019404.V338533.R01.S.doc Version 5.2 Page 17 Whistleblowing procedure. Four out of the six service users who completed survey forms, with the support of staff, said that staff treated them well. One person answered ‘no’ and another person ‘sometimes’. Four people said they felt safe. The two people who responded saying they felt safe ‘sometimes’ also said they felt well cared for and were treated well by staff. The survey responses were reviewed and no negative comments were received from service users during the inspection. The Commission was notified between inspections that money had been identified as missing from the locked boxes kept for each service user in the office. The police were involved and crime numbers issued to four service users. It was reported that Mencap have carried out an internal investigation into the incident that occurred in January but it appears a final report has not been issued. The manager reported the service users have been reimbursed. Two people are now carrying out daily checks on the money being kept on behalf of service users. Hardy Drive (23) DS0000019404.V338533.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): Standards 24 & 30 - People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users live in a bright modern home, which has benefited from a recent refurbishment of the sensory room and shower room EVIDENCE: The development of a more person centred approach to care planning has enabled staff to decorate the bedrooms of service users in a style that reflects their interest and sensory needs. The sensory room has now been completely revamped by staff and can now be used by service users. The effects of damp in the shower room have now been eliminated. Redecoration has taken place and an extractor fan installed. The lounge, conservatory and kitchen-diner have up to date furniture and fittings in place that enable service users and staff to spend time comfortably Hardy Drive (23) DS0000019404.V338533.R01.S.doc Version 5.2 Page 19 together. Aids and adaptations are available for service users who require them and risk assessments are in place for the safe use of equipment. All areas of the home were found to be fresh and clean. There are suitable arrangements in place for service users to manage their laundry. A review of hand washing arrangements needs to be carried out according to Department of Health Guidance, as service users and staff were sharing linen hand towels in the communal bathrooms and toilets. Staff said they would wash their hand in the hand basin provide in the kitchen. Liquid soap and disposable hand towels need to be available at the point of contact to reduce the risk of infection spreading. Hardy Drive (23) DS0000019404.V338533.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): Standards 32, 34 & 35 - People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are supported by a staff team who are familiar with their needs, can respond flexibly to changing circumstances and they appear to have good relationships with. There are robust recruitment procedures in place to ensure that suitable people are employed and are given the training they need to work effectively and develop their skills. EVIDENCE: The service users appeared to have a positive relationship with the staff on duty. A pictorial calendar with photographs of the staff on duty for the next few days is used to provide service users with information about who will be joining them. The inspector asked service users about the people shown and received positive responses. The funding arrangements mean hardy Drive is not staffed during the day when service users are attending their daytime activities. This means staff have to respond individually to service users who may be unwell and need to Hardy Drive (23) DS0000019404.V338533.R01.S.doc Version 5.2 Page 21 stay at home. Additional funding is obtained where a higher level of staffing is required to meet specific needs. Mencap bank and agency staff are used to address shortfalls in staffing and cover the permanent staff that are providing additional one to one support for a service user. The records of four staff recruited since the last inspection were reviewed. This confirmed that two references and a Criminal Records Bureau check are received before that new staff start work, to check they are suitable to work with vulnerable people. The records were well organised with application forms, interview notes, medical clearance, contracts and supervision records in place. The staff records and interviews confirmed that staff receive support when they start work and benefit from a planned programme of training which progresses from induction to LDAF learning disability foundation training and NVQ training. Mencap also provides a wide range of additional training to enhance the skills and confidence of staff. There are systems in place to ensure staff receive regular one to one supervision to review their practice and contribute their views on the running of the service. Hardy Drive (23) DS0000019404.V338533.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): Standards 37, 39 & 42 - People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are appropriate management, quality assurance and health & safety systems in place to protect the people who live and work at Hardy Drive. However the manager should review the opening distance of first floor windows to reduce the risk of falls from a height. EVIDENCE: The manager is registered with the Commission as required but needs to complete the NVQ Registered Managers Award and associated care qualifications, which are the standards set for managers of care homes to achieve. Hardy Drive (23) DS0000019404.V338533.R01.S.doc Version 5.2 Page 23 The management and staff team supported by Mencap polices and procedures, demonstrate a commitment to creating a positive, open and inclusive environment for the service users. There are robust quality assurance systems in place within the home and wider organisation, for auditing and reviewing the service provided and making sure the views of service users are heard. One of the service users attended a national Mencap event at the House of Commons. The manager’s quality review included a poster presentation on the views of service users. Staff receive the training they require to promote safe working practices. New staff had received food hygiene, first aid, moving and handling and fire training. Generally there are well organised systems in place for carrying out regular health & safety audits. This ensures the required checks on equipment and systems are carried out within the timescales required. However although the first floor windows have high sills and require two handles to be operated to open them, the opening gap on some were wider than health & safety guidance for vulnerable people. The manager needs to review the risk assessments and carry out any necessary adjustments to further reduce the risk of accidental falls from height. The service users are involved in testing the fire procedures within the home. Hardy Drive (23) DS0000019404.V338533.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 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 2 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 4 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 x 4 x x 2 x Hardy Drive (23) DS0000019404.V338533.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 YA23 Regulation 13(6) Requirement Timescale for action 2 YA30 13(3) 3 YA42 13(4) To identify the issues and reduce 30/09/07 risk in the future the Registered Provider must provide the Commission and manager of the service with a report on the outcome of the investigation into the alleged theft of service user’s money that was identified in January 2007. To reduce the risk of infection 30/09/07 liquid soap and disposable paper towels must be made available to service users and staff in areas where personal care is carried out including, communal toilets and bathrooms. To reduce the risk of accidental 31/07/07 falls from height the opening distance for first floor windows and the individual risk assessments for each person and people who may have access to the rooms must be reviewed. Hardy Drive (23) DS0000019404.V338533.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hardy Drive (23) DS0000019404.V338533.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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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