Inspection on 06/09/05 for Keats Way, 97

This inspection was carried out on 6th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 but made no statutory requirements on the home.

Other inspections for this house

Keats Way, 97 22/05/07

Keats Way, 97 04/04/06

Keats Way, 97 12/04/05

Keats Way, 97 05/07/04

Keats Way, 97 25/06/04

Keats Way, 97 18/06/03

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

CARE HOME ADULTS 18-65 97 Keats Way Greenford Middlesex UB6 9HF Lead Inspector Sarah Middleton Unannounced 6 September 2005 9.25 AM 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 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 Stationary 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. 97 Keats Way G61-G10 s27753 Keats Way v214779 060905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 97 Keats Way Address Greenford, Middlesex UB6 9HF Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0208 575 3986 0208 575 8632 Mr Rajgopal Ramanah Mr Rajgopal Ramanah Care Home 4 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (0) 97 Keats Way G61-G10 s27753 Keats Way v214779 060905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 12/4/05 Brief Description of the Service: Keats way is a large end of terraced house on a corner plot in a residential area. The property is situated on the borders of Greenford and Southall. It is near to small local shops and a short distance by transport to a larger town. A bus route runs nearby providing transport to mainline railway and underground services, which are only a few miles away. There is a small front paved front garden and an enclosed back garden, with a small patio and grass area.The home is registered for four people, with an age range between 18 years old to above 65 years old, with a mental disorder. There is one bedroom situated on the ground floor, which has an en-suite facilities. The other three bedrooms are located on the first floor, along with a sleeping in bedroom for staff. This means that primarily the home caters for service users who can manage the stairs. The communal rooms are located on the ground floor, where there is a separate dining room and lounge. The home is staffed twenty four hours a day and can provide personal care or assistance with personal care and supervision for people with mental health needs. 97 Keats Way G61-G10 s27753 Keats Way v214779 060905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of just over three hours, 9.25am-12.45pm, was spent on the inspection process. The Inspector carried out a tour of the home and inspected service user plans, staff files and maintenance records. One service user and the Registered Manager were spoken with as part of the inspection process. It must be noted that it is sometimes difficult to ascertain the views of service users with mental health needs. The home had met many of the previous requirements, although several new requirements were made following this inspection. The home has one service user vacancy. What the service does well: What has improved since the last inspection? The home has met several previous requirements and has improved the contents of care plans. These are reviewed regularly with the service user and any comments service users make are now noted in the care plans. There has been a slight improvement in the activities offered and it is clearly noted on individual’s care plans where there are difficulties in engaging service users to take part in activities. There is now some evidence of courses staff attend and these are both external and internal courses. There has also been a slight improvement regarding risk assessments. Overall, except the one area noted in the report, these assessments were up to date and relevant to the individual service user. 97 Keats Way G61-G10 s27753 Keats Way v214779 060905 Stage 4.doc Version 1.40 Page 6 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. 97 Keats Way G61-G10 s27753 Keats Way v214779 060905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection 97 Keats Way G61-G10 s27753 Keats Way v214779 060905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3 & 5 Prospective service users are assessed to ensure the home can meet their needs. Staff receive ongoing information and training predominantly from the Registered Manager. This is provided to meet the needs of the service users. It is recommended that the Registered Manager provides staff with the opportunity to attend external courses on subjects such as Mental Health issues. Service users are offered terms and conditions to ensure they are fully aware of the services they can receive and the conditions they need to know with regard to living in the home. EVIDENCE: Service users are assessed prior to their admission into the home. Preadmission documentation was viewed and contained all relevant details of the service users needs. There is a prospective service user who has recently visited the home. The Registered Manager stated they would carry out their own assessment, in addition to any information or Social Services assessment they might obtain. 97 Keats Way G61-G10 s27753 Keats Way v214779 060905 Stage 4.doc Version 1.40 Page 9 Recently staff received training from the Registered Manager with regard to Alcoholism, Mental Health and Challenging Behaviour. This is to ensure the staff team have an awareness of the complex needs of the service users living in the home and can meet the needs of a prospective service user. Terms and conditions were seen on individual’s care plans and outlined information relevant about the home. 97 Keats Way G61-G10 s27753 Keats Way v214779 060905 Stage 4.doc Version 1.40 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 & 9 There has been an improvement in the details of the care plans and the Registered Manager has been exploring ways to improve the care plans and how they are presented. Where possible service users are included in the completion and review of their care plan. Their requests and suggestions are acknowledged and recorded by the Registered Manager. Where possible the home seeks ways to act on the suggestions made by service users. However there were shortfalls regarding daily records. They must be informative and detail the care and mood of the service user to ensure all relevant information is shared amongst staff. Although there has been an improvement in the detail of risk assessments, there must be a risk assessment for service user/s who might be alone in the home. A detailed risk assessment would safeguard the service user and other service users and staff. 97 Keats Way G61-G10 s27753 Keats Way v214779 060905 Stage 4.doc Version 1.40 Page 11 EVIDENCE: Individual service users care plans were viewed. These gave an overall picture of the service users needs. The Registered Manager completes the care plans and reviews them monthly with the service user. It was noted on care plans likes/dislikes and interests. In addition care plans described service users abilities to take part in daily living activities and where they required assistance. However a sample of daily records viewed were sparse and offered no details on the mood and mental health of the service user and lacked detailed information about activities the service user had taken part in that day. A requirement was made for daily records to contain sufficient and relevant detail that can inform staff about the service user. The home has sought the views of service users in the form of a questionnaire. All of the three service users living in the home contributed and answered as much as they were able to. As noted above service users are now consulted about their care plans and discussions take place if there are any disagreements. Service users meetings also take place and minutes were viewed which showed that all service users communicated where they were able. Risk assessments were in place and had been up dated and reviewed by the Registered Manager. However there was no risk assessment in place if one of the service users, (who has a front door key) returned to the house when there was no one else present. Although the Registered Manager stated they always return before they expect the independent service user to return to the house, a requirement was made that a through risk assessment is completed. 97 Keats Way G61-G10 s27753 Keats Way v214779 060905 Stage 4.doc Version 1.40 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 16 & 17 There have been efforts made to either increase activities or to record where service users have difficulties or little interest in activities suggested by staff. However there continues to be a shortfall in fully addressing service users leisure interests and how these can be accessed. Although there are difficulties in motivating service users, the home must continue to explore ways to stimulate and encourage service users to take part in activities in the community. Service users rights are respected and they are supported by staff to take responsibility for areas of their life they feel confident to. Meal provision in the home meets the needs and preferences of service users and fresh nutritious meals are available each day. This encourages service users to maintain a healthy weight. 97 Keats Way G61-G10 s27753 Keats Way v214779 060905 Stage 4.doc Version 1.40 Page 13 EVIDENCE: There has been a slight improvement in the home recognising the need to ensure service users are offered the opportunity to take part in a variety of activities both in and out of the home. It is noted on all care plans service users preferences and dislikes regarding activities. The service users living in the home are not able to seek employment and do not have any interest to attend college. Where possible staff support service users to visit and access local community resources. One service user stated they visit the pub with staff to see their old friends. However they said they do not go as often as they would like. One service user is independent and goes out every day for long walks. This usually entails visiting the local golf club where they meet up with people they know. The Registered Manager stated they seek alternatives for service users but for most of the time they do not wish to go to any places suggested. There are no examples of options/activities staff offer to service users. It is not clear what are some of the service users leisure pursuits or interests. There is no structure to service users daily routine, other than one service user attends a local community mental health team for art and craft sessions twice a week. The feedback from one Care Manager and the service users is that they would like more activities. This was a re-stated requirement as the home must look at planning for activities and ensuring there are sufficient numbers of staff working to support service users in activities. Holidays do not take place but the Registered Manager stated day trips are offered. There was no evidence to support this statement. The Registered Manager stated all service users receive their personal mail. It is noted if service users cannot have a front door key. The Registered Manager was seen to interact with the service users positively throughout the inspection. Meal times are well managed. Menus were viewed and fresh fruit and vegetables were seen at the time of the inspection. The kitchen floor has been replaced and the kitchen was clean and tidy. Fridge temperatures are taken and recorded on a daily basis. Where possible service users are encouraged to assist staff in preparing meals. 97 Keats Way G61-G10 s27753 Keats Way v214779 060905 Stage 4.doc Version 1.40 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 20 Some health needs were being met, but it was not clear from care plans what health professionals service users accessed and if there were health professionals that service users refused to access. The home must consider service users health needs and how they are able to support service users in accessing all relevant health professionals on a regular basis. Medication systems are in robust in the home which safeguards service users health and safety. EVIDENCE: Service users access health care professionals such as Psychiatrists and GP’s. At the previous inspection one service user had refused to attend an out patients appointment with a Psychiatrist, this has now been resolved and they attended a recent review. However it is not clear if they also access Dentists, Opticians and other possible relevant professionals. Care plans must clearly evidence how health needs are being addressed and where service users refuse to access a particular health professional then this must be recorded. Any action taken by the home to address a health need must also be recorded. 97 Keats Way G61-G10 s27753 Keats Way v214779 060905 Stage 4.doc Version 1.40 Page 15 Medication systems in the home were viewed for the two service users taking prescribed medication. Medication administration records were completed correctly and no errors were found. No service users self-medicate and there are no controlled drugs. 97 Keats Way G61-G10 s27753 Keats Way v214779 060905 Stage 4.doc Version 1.40 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 The home has a satisfactory complaints system and has not had any complaints. One service user spoken with felt confident that any concerns or complaints they had would be listened to and acted upon. Documentation is in place with regard to the protection of vulnerable adults, however staff have not received any training on this subject. This must occur in order to ensure the staff have the knowledge and understanding so that they can protect service users from abuse. EVIDENCE: The home has a complaints procedure that is visible in the communal area of the home. One service user spoken with stated if they were unhappy about something they would take their concerns to the Manager. There have been no complaints since the last inspection. The home has a policy and procedure for the protection of vulnerable adults (POVA). In addition the home has documentation from the Government on the subject of whistle blowing and abuse along with the Local Authority’s policy and procedure on POVA. The Registered Manager had written to the Local Authority asking when the next POVA training would be available. However, he has not heard of any local courses. A requirement was made that staff must receive training, or through other measures, on the subject of POVA. 97 Keats Way G61-G10 s27753 Keats Way v214779 060905 Stage 4.doc Version 1.40 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 29 & 30 Whilst previous maintenance issues have been addressed, other areas of the home were identified as needing attention. There must be planning for the overall ongoing maintenance, refurbishment and redecoration of the home to ensure it is a safe, welcoming and comfortable environment for service users. The home must ensure the home provides adaptations for those service users requiring additional support and assistance to safely access all areas of the home. EVIDENCE: During the tour of the home the dining room was noted as needing decoration and refurbishment. The carpet was poorly fitted and had burn marks on it. This room is for meals and where the service users smoke. The Registered Manager acknowledged that this room needed attention and a requirement was made that the carpet must be changed for more suitable flooring. The Registered Manager stated he would consult with the service users to ascertain what colour they would want in the dining room. A requirement was made at the previous inspection regarding the kitchen flooring. This had been replaced and was now securely fitted. The Registered Manager must monitor the home as areas needing attention have been highlighted in previous inspections. 97 Keats Way G61-G10 s27753 Keats Way v214779 060905 Stage 4.doc Version 1.40 Page 18 The maintenance of the home is important so that it is a warm and homely environment for service users. There is no programme for redecoration and refurbishment this must be in place in order for the home to regular address rooms that will require attention. A requirement was made that the Registered Manager completes an action plan for the maintenance of the home. The home has some adaptations for those service users requiring assistance. However from the dining room to the garden there are no grab rails. This must be in place for one particular service user who regularly uses the garden but needs support to go up and down steps. A requirement was made that this is put in place. The home was clean and free from odours. Staff had recently attended a health and safety course that included the subject of infection control guidelines. The washing machine and dryer is located in a small cupboard in the dining room. The Registered Manager is exploring ways to minimise the noise this makes. 97 Keats Way G61-G10 s27753 Keats Way v214779 060905 Stage 4.doc Version 1.40 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35 & 36 The staff team is small at the home and the rota reflects the needs of the three service users living in the home. The numbers of staff working at the home will need to be reviewed if the service user vacancy is filled. Staff receive information and training however the home does not have any staff studying an NVQ course. Staff must enrol on this training to ensure they have the skills and knowledge to meet the needs of the service users. The home must have a clear and detailed induction programme for all new staff and there must be evidence of the subjects covered during the induction. The vetting and recruitment systems are robust and aim to protect and safeguard service users. EVIDENCE: The rota was viewed and confirmed that for the most part there is one member of staff working in the home. However, when there are appointments additional staff work in the home. The Registered recently employed a Deputy Manager who works two days a week, which also enables service users to go out on a one to one basis. 97 Keats Way G61-G10 s27753 Keats Way v214779 060905 Stage 4.doc Version 1.40 Page 20 The Deputy Manager’s role and hours are flexible and the Registered Manager stated this new staff member could work additional hours or days as and when needed. Discussions took place with the Registered Manager with regard to staffing numbers and the recommendation is that should the service user vacancy be filed, staffing levels would need to increase. There is a list of the training individual staff have attended. The Registered Manager carries out the majority of training. It is recommended the Registered Manager also explores external specialist training for staff. Staff have requested further training on particular areas of interest, for example benefits and additional mental health training. Currently no staff are studying or have enrolled to complete an NVQ course. A requirement was made that this must occur. Staff files contained details of training they had received, however there was no evidence of the subjects covered in the induction for the new staff member. The Registered Manager showed a checklist they go through with all new members of staff, however, this had not been completed. Staff receive training in various areas such as moving and handling, basic 1st Aid and medication. As noted earlier the Registered Manager must identify training on the protection of vulnerable adults. Staff receive supervision and support on a regular basis. The staff employment files viewed contained details of the applicants completed application forms, Criminal Record Bureau checks, medical declaration, two references, photograph and terms and conditions of employment 97 Keats Way G61-G10 s27753 Keats Way v214779 060905 Stage 4.doc Version 1.40 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39 & 42 The Registered Manager must enrol on a relevant managerial course to ensure they are up to date with their knowledge and skills. The home has begun developing a review of the quality of care offered in the home. Views were sought from all relevant people and a summary of their responses was available. This will enable the home to reflect on the comments and suggestions, act on both the positive/negative remarks and seek ways to improve the home for the benefit of the service users. EVIDENCE: The Registered Manager has managed and owned the home for many years. However a requirement was made that they undertake a relevant management qualification. 97 Keats Way G61-G10 s27753 Keats Way v214779 060905 Stage 4.doc Version 1.40 Page 22 The home has gathered the views of service users, family members and from professionals. The Registered Manager has produced a brief summary of those findings. It is recommended that the Registered Manager expands this procedure for reviewing the care offered in the home and encourages the staff and the Manager to review the home and its internal systems to ensure any shortfalls are identified and action is taken to rectify any issues arising from the audit. Samples of the maintenance records were viewed. Water temperatures are taken on regularly, fire equipment had been serviced and was up to date, as was the Gas Safety Record. Fire drills have taken place but it was not clear at what time and any issues that may have arisen following a fire drill. A requirement was made that fire drills must take place at different times of the day and night with different staff present at each drill. 97 Keats Way G61-G10 s27753 Keats Way v214779 060905 Stage 4.doc Version 1.40 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 3 x 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x 2 3 Standard No 11 12 13 14 15 16 17 3 3 3 2 x 3 3 Standard No 31 32 33 34 35 36 Score 3 2 3 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 97 Keats Way Score x 2 3 x Standard No 37 38 39 40 41 42 43 Score 2 x 3 x x 2 x G61-G10 s27753 Keats Way v214779 060905 Stage 4.doc Version 1.40 Page 24 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 6 Regulation 17 (1) (a) Requirement Timescale for action 3/10/05 2. 9 3. 14 4. 19 5. 23 6. 7. 8. 24 24 24 Daily records must record details of the care and any other relevant information regarding a service user. 13 (4) ( c) There must be in place a detailed risk assessment with regard to service user/s being alone in the home. 16 (2) (n) Appropriate opportunities to engage in leisure activities and hobbies must be available for service users. (Previous timescale 30/6/05 not met) 12 (1) & The home must ensure there are (2) & (3) clear health records available in order to ensure service users health needs are being addressed. 13 (6) The Registered Person must make arrangements, by training staff, or by other measures, on the protection of vulnerable adults. 23 (2) (d) The toilet seat in the main bathroom must be replaced. 23 (2) (d) The flooring in the dining room must be replaced and the dining room re-decorated. 23 (2) (b) An action plan must be drawn up & (d) to address ongoing maintenance G61-G10 s27753 Keats Way v214779 060905 Stage 4.doc 10/10/05 31/10/05 31/10/05 30/11/05 10/10/05 30/11/05 30/11/05 Page 25 97 Keats Way Version 1.40 9. 29 23 (2) (n) 10. 32 18 (1) (a) & (c ) (i) (ii) 11. 35 18 (1) (a) & (c ) (i) 9 (2) (b) (i) & 10 (3) 23 (4) (e) 12. 37 13. 42 issues and areas that either need or will need attention. Timescales to complete any work must be included on the action plan. A copy must be forwarded to the CSCI. The home must provide suitable adaptations in the home, for example there must be a grab rail from the dining room into the garden. The Registered Person must ensure that there are suitably qualified staff working in the home and that staff undertake training in the NVQ course or equivalent. There must be evidence available regarding the contents of the induction new members of staff receive. The Registered Manager shall undertake training that is appropriate to ensure they have the skills necessary to manage the home. Fire drills/practices must be at suitable intervals and times to ensure all staff and service users are familiar with the procedure. 31/10/05 30/11/05 31/10/05 30/11/05 31/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 33 35 39 Good Practice Recommendations A review of staffing levels should take place if the service user vacancy is filled. The Registered Manager should explore external training on specialist areas, such as Mental Health & Alcolholism for members of staff. The quality assurance systems should be looked at and expanded where necessary to incorporate an overallreview of the home and its internal systems. G61-G10 s27753 Keats Way v214779 060905 Stage 4.doc Version 1.40 Page 26 97 Keats Way 97 Keats Way G61-G10 s27753 Keats Way v214779 060905 Stage 4.doc Version 1.40 Page 27 Commission for Social Care Inspection Ground Floor 58 Uxbridge Road Ealing, London W5 2ST National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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