Inspection on 01/11/07 for Jewish Care

This inspection was carried out on 1st November 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Jewish Care 24/07/06

Jewish Care 21/12/05

Jewish Care 25/05/05

Jewish Care 30/09/04

Jewish Care 20/05/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Jewish Care 7b Mapesbury Road London NW2 4HX Lead Inspector Andreas Schwarz Key Unannounced Inspection 1st November 2007 09:00 DS0000017467.V344004.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 DS0000017467.V344004.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. DS0000017467.V344004.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Jewish Care Address 7b Mapesbury Road London NW2 4HX 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 8459 2569 020 8459 4855 Jewish Care Manager post vacant Care Home 25 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (25), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (20) DS0000017467.V344004.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th July 2006 Brief Description of the Service: 7b Mapesbury Road is a purpose built house with a very large well-maintained garden at the rear of the property. It is in a quiet residential road, but within walking distance of good public transport links and close to Kilburn High Road shopping centre. The home is run by Jewish Care and provides accommodation for 25 adults with mental health problems. A registration variation has been given in order to accommodate people using the service over the age of 65. All people using the service have good-sized single rooms and there are five flats with en-suite facilities. There is a large dining/lounge area on the ground floor that opens out to a beautifully maintained garden and two further lounges on the first and second floor, one of which accommodates people using the service who smoke. There is off-street parking at the front of the property. Information on fees and charges can be obtained from the manager on request. DS0000017467.V344004.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place during early November 2007 and lasted 7 ½ hours. The new manager Mrs Anthea Jones was not available at the start of this inspection, but was available during late morning to assist myself. I have left 10 user-friendly surveys for people using the service to fill out, seven of these have bee returned before the end of this field visit. The home has returned an Annual Quality Assurance Assessment form within the given timescale. The Annual Quality Assurance Assessment was filled out to high standard and provided myself with valuable information about the home and service provided. I spoke to four people using the service and two support workers at lengths. I observed staff working with people using the service and was invited to sample lunch by people using the service and manager. I would like to take this opportunity thanking everybody involved in this key inspection. What the service does well: Ealon House (7b Mapesbury Road) is well managed and staff as well as people using the service spoke positive about the new manager Mrs Anthea Jones. The home has a very experienced staff team supporting people using the service with mental health and age related problems. People using the service are consulted regularly regarding the care and support received and a range of suitable activities is provided. The homes literacy group has published a book with poems and stories written by people using the service about their live and living in Ealon House, which is commendable. Service users care plans have been updated and are of very good standard and residents’ involvement is evident throughout. The home is providing a wide range of activities and has 25 different activities for people using the service to choose from. Activities are facilitated by an activity co-ordinator and participation is clearly recorded. DS0000017467.V344004.R01.S.doc Version 5.2 Page 6 The home is providing kosher food, and is inspected by the London Beth Din Kashrut Society to ensure food is kosher and is prepared according to Jewish Law. 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. DS0000017467.V344004.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 DS0000017467.V344004.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): People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. New prospective people using the service receive detailed information about the home, and are assessed appropriately, to establish if the home is able to meet their needs. EVIDENCE: The home has forwarded a copy of the service users guide and statement of purpose to the Commission for Social Care Inspection, both documents are judged compliant with National Minimum Standards. The home has detailed needs assessments for new prospective people using the service in place. All three care plans viewed by myself confirmed this. People using the service informed me that they have been involved in the assessment process and they themselves or their representative sign all assessment documents; assessment information form part of the care plan. The home has currently four vacancies and no new admissions into Ealon House have been made since the last inspection. DS0000017467.V344004.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): People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The service involves individuals in the planning of care that affects their lifestyle and quality of life. The care plans are person centred and are agreed with the individual. The care plan includes a comprehensive risk assessment, which is regularly reviewed. The service has a ‘can do’ attitude and risks are managed positively to help people using the service lead the life they want. . People using the service make their own informed decisions and have the right to take risks in their daily lives. EVIDENCE: I have viewed and assessed three care plans during this key inspection. The care planning system is based on the Standex system; all care plans have been reviewed and updated since the last key inspection. Care plans are person centred and provided detailed information about the person as well as guidelines for staff supporting people using the service. People using the service informed me that they are aware of their care plans and meet with DS0000017467.V344004.R01.S.doc Version 5.2 Page 10 their key worker regularly to discuss objectives. Care plans address peoples religious preferences and activities. Care plans are provided in a user-friendly format, for example on of the people living in the home speaks Spanish and the care plan is available in his first language as well as in English. The home has analysed people’s level of independence, to ensure that the home is still meeting peoples changing needs due to increasing age. A new form has been introduced in the care plan, which allows staff to monitor age related issues such as decrease in mobility, increase in falls, Dementia, etc. I have observed people using the service leaving the home independently. People using the service finances have been assessed and all of them have been correct, the home is recording income and expenditure on the computer. An administrator is responsible for the upkeep of the financial ledger, which is regularly audited by the finance manager. The manager Mrs Jones did not demonstrate knowledge of this process and informed me that she has not been inducted in the procedure, this is required. People using the service have regular meetings to discuss any issues relating to the home. The home has updated and reviewed risk assessments. All files viewed have a mental health risk assessments in place. People using the service have environmental risk assessments such as smoking in their room, fire, etc as well as person specific risk assessments such as community access, self harm, falls assessment in place. Risk assessments are drawn up and reviewed together with the person. The manager demonstrated very good knowledge of risk assessment processes. DS0000017467.V344004.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): People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The service has a strong commitment to enable people who use services to develop their skills, including social, emotional, communication, and independent living skills. Individuals are supported to identify their goals, and work to achieve them. People who use the service have the opportunity to develop and maintain important personal and family relationships. People who use services are involved in meaningful daytime activities of their own choice and according to their individual interests and capability. Meals are very well balanced and highly nutritional and cater for varying cultural and dietary needs of the people who use services. EVIDENCE: One person using the service informed me that he is currently playing the piano in another Jewish Care home on a voluntary basis. Jewish Care has an DS0000017467.V344004.R01.S.doc Version 5.2 Page 12 Education and Development Committee Forum for people with mental health problems. The forum is looking at employment prospects and community workshops and helps people using the service to explore work and educational prospects. People using the service can also access a Jewish day service if they wish to do so. The home is promoting the Jewish way of life, and Jewish festivals and holidays such as Shabbat, Chanukah, Rosh Hashanah, etc. During the most recent Purim celebration the home was visited by the local synagogue and local school children. People using the service informed me that they go to\local hairdressers, local shops, barbers, cinemas, etc. One person told me that he has recently been to Willesden Library. People using the service are encouraged to use public transport and have a Freedom Pass to use. I observed staff interacting professionally and sensitively to people’s needs and requests. The home has an activity co-ordinator employed who meets regularly with people using the service to discuss current and new activities. People’s participation in activities is recorded in their care plan and the home offers around 25 different planned activities ranging from women’s and men’s group, bingo, arts, etc. The home is encouraging people to have meaningful relationships. People using the service families and relatives are actively encouraged to take part in their lives. One person using the service informed me that he could invite friends and families for meals, provided the chef has been informed. The home has a relative’s forum, which enables relatives to comment on the home. One person showed me letters he was in the process of sending to his brother in Israel and told me that he is regularly calling family in England and abroad. All people using the service are issued with a front door and bedroom key and depending on their risk assessment can go out independently or with staff support. I observed people accessing all areas in the home and picking up their unopened mail from the office. People using the service can choose to be on their own or with others. Meals are nutritious and varied. The home employs a contractor to provide cooked meals. All meals are Kosher and are monitored by the London Beth Din Kashrut Society. People using the service have at least two meal choices and three hot meals are provided daily. People using the service informed me that the quality of food has improved since kitchen staff has changed. The chef is meeting people using the service every two weeks to discuss menus and meal choices. The home has recently prepared a new menu together with people using the service. I was invited to sample lunch, which was nicely prepared and tasted very good. During this visit the home received a delivery of new kitchen utensils, tablemats, salt and pepper dispensers, etc. The home has a complaints book, which allows people using the service to raise their dissatisfaction about meals anonymously. DS0000017467.V344004.R01.S.doc Version 5.2 Page 13 DS0000017467.V344004.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): People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Personal healthcare needs including specialist health, nursing and dietary requirements are clearly recorded in each person’s plan. Personal support is responsive to the varied and individual needs and preferences of the people who use services. People who use services have access to healthcare and remedial services. The home has an efficient medication policy supported by procedures and practice guidance, which staff understand and follow. People who use services are given the support they need to manage their medication. EVIDENCE: During the initial assessment the home is looking at Health issues, personal care ability, domestic abilities, this is than followed through in the care planning process. The majority of people using the service are able to wash and dress themselves independently. People using the service informed me that at times staff reminds them if they have forgotten to shave or look scruffy. People using the service have been dressed appropriately and clean during this key inspection. The manager showed me a medi bath in one of the bathrooms; she informed me that people with mobility problems use this bath. DS0000017467.V344004.R01.S.doc Version 5.2 Page 15 The bath is very old and people using the service can only sit upright while having a bath. I recommend reviewing this and providing more suitable facilities for people choosing to have a bath. People using the service have access to chiropodist, dentists, psychiatrist, psychologist through community services and local mental health facilities. All people using the service are registered with their own General Practitioner. Visits from clinicians are recorded in care plans. The home is also recording if people using the service choose not to access these facilities. The General Practitioner facilitates annual health checks. A local pharmacist provides medication to the home. Medicines are stored in a lockable cabinet in the office. The assistant manager is responsible for the ordering of medication. The pharmacist is undertaking regularly visits to the home to assess if storage and administration is appropriate and compliant with statutory requirements. One of the people using the service is selfadministering and appropriate risk assessments are in place. I noted the temperature of the medicines fridge is not monitored; this is required. The home is using the fridge to store insulin, the individual Epi pens are not labelled this is required. Once Epi-pens are opened the insulin expires within 28 days, the home must ensure to record the day of opening. DS0000017467.V344004.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): People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has an open culture that allows people using the service to express their views, and concerns in a safe and understanding environment. The home does not always inform the Commission for Social Care Inspection of notifiable incidences. The policies and procedures for Safeguarding Adults are available and give clear specific guidance to those using them. EVIDENCE: The home has received one complaint since the last key inspection; this complaint has been resolved within the 28 days timescale. The home has a detailed complaints policy in place and people using the service informed me that they know who to complain to. One person made a complaint during this key inspection; the manager followed this up. I noted in one persons file that a person using the service had a fall and was taken to hospital; this was not reported to the Commission for Social Care Inspection, which is required. The home did not make a Protection of Vulnerable Adults referral since the last inspection. Staff has received Protection of Vulnerable Adults training and detailed adult protection policies are in place. The home has obtained Protection of Vulnerable Adults guidelines from funding boroughs. The manager informed me that the home has a whistle blowing, violence and aggression, etc. policy in place. DS0000017467.V344004.R01.S.doc Version 5.2 Page 17 DS0000017467.V344004.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): People using the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that meets the specific needs of the people who live there. The home is comfortable, and has a programme to improve the decoration, fixtures and fittings. Occasionally there is slippage of timescales and maintenance tends to be reactive rather than proactive. The home is well lit, clean and tidy and smells fresh. The management has a good infection control policy; they seek advice from external specialists. EVIDENCE: The home has repainted the communal areas and replaced carpets in the hallways since the last inspection. The sleep in facilities have been relocated to the second floor. During a tour of the premises I noted a number of issues, which have to be addressed. In the ground floor bathroom tiles were missing, which have to be replaced. The missing toilet roll dispenser and shower curtain must be replaced. The WC on the first floor was locked due to a fault, the DS0000017467.V344004.R01.S.doc Version 5.2 Page 19 home must repair the toilet to provide suitable facilities for people using the service. The utility room is located on the ground floor and a washing machine as well as clothes dryer is provided. The home was clean and free of any offensive odours. The home has contracted a cleaning company who is responsible to take care of the premises and laundry. A housekeeper is providing a weekly audit to the manager. The manager of the cleaning company monitors infection control and Control of Substances Hazardous to Health. DS0000017467.V344004.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): People using the service experience excellent outcomes in this area This judgement has been made using available evidence including a visit to this service. Management prioritise training and facilitate staff members to undertake external qualifications beyond the basic requirements. The content of the induction and probationary periods are seen to be very robust, detailed and service specific. The service only confirms permanent employment when satisfied that competence and progress has been shown to be satisfactory against their high standards. EVIDENCE: The manager informed me that there are currently three vacancies, but recruitment has already started. Staff employed by the home has different levels of experience and qualifications. Staff employed reflects the cultural background of people using the service. I observed staff talking to clinicians and community nurses; this was done professionally. All staff has or is in the process of achieving necessary qualifications in care. The home does not employ staff under the age of 18. The home has a detailed recruitment policy in place. All staff is issued with the General Social Care Councils Code of Conduct. I have viewed staff files and DS0000017467.V344004.R01.S.doc Version 5.2 Page 21 noted that some files do not contain the necessary information. The manager is aware of this and has drawn up a list of the missing documents. She is currently in the process of getting these documents from Jewish Care human resource department. All staff undertakes six months probation before being confirmed in post. Staff receives a wide range of training. All staff has an updated training and development plan in place. Training needs are addressed in supervisions, which are held regularly. The home has a separate training budget in place. The organisation has recently introduced 10-day induction training, which is in lane with the Sector Skills Council workforce strategy targets. The home undertakes fortnightly staff meetings records of these have been made available for inspection. DS0000017467.V344004.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): People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The Manager has the required qualifications and experience and is competent to run the home. The home provides value for money. She works to continuously improve services and provide an increased quality of life for people using the service with a strong focus on equality and diversity issues. EVIDENCE: The Head of Home (who started in January 2007 & has yet to be registered) has over 10 years of experience as a registered manager working in the mental health field. She has National Vocational Qualification in Care Level 4, a Registered Managers Award and is a qualified assessor in care. She is undertaking numerous training as part of personal devlopment e.g. ILM5 in Management, OFI course in training to become a qualified manual handling DS0000017467.V344004.R01.S.doc Version 5.2 Page 23 trainer. People using the service and staff gave very positive feedback about the manager and I could see during this inspection that records, care plans, etc. have been updated. The home has a range of quality assurance measures in place; records of these are kept in individual files. I have viewed a business development plan for 07/09, which looks at maintenance, people using the service, staffing, etc. The manager is undertaking monthly site visits and Health and Safety audits. The organisation has a good track record of undertaking regular provider visits and is forwarding copies of these records to the Commission for Social Care Inspection. The annual development plan has been updated on 11/07/07. Service users surveys are available in foreign language if required. Portable Appliances Test Certificate, Landlords Gas Safety Certificate, fire tests and fire equipment checks are up to date. DS0000017467.V344004.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 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 3 33 X 34 3 35 4 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 X 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X DS0000017467.V344004.R01.S.doc Version 5.2 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA7 Regulation Requirement Timescale for action 01/12/07 18(1)(c)(i) The manager must receive training in regards to the recording and auditing of people using the service financial records. 13(2) Medicines fridge temperatures must be monitored and recorded daily. (Previous Timescale of 15/08/06 not met) 2. YA20 01/12/07 3. YA20 13(2) The home must ensure to have all Epi pens labelled individually and record the date of opening to ensure best before dates have not expired. The manager must ensure that all notifiable incidences are reported to the Commission for Social Care Inspection without delay. 01/12/07 4. YA22 37 01/12/07 5. YA24 23(2)(a-d) The following items on the ground floor bathroom must be repaired or replaced: • Missing tiles • Missing toilet roll dispenser DS0000017467.V344004.R01.S.doc 15/12/07 Version 5.2 Page 26 • 6. 7. YA24 YA37 23(2)(c) 8,9,10 Missing shower curtain. 15/12/07 01/01/08 The broken WC on the 2nd floor must be repaired. The permanent manager must be registered with the Commission for Social Care Inspection. 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. Refer to Standard YA18 Good Practice Recommendations The home should review bathing facilities for people with mobility problems. 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