Inspection on 02/06/06 for Kenilworth

This inspection was carried out on 2nd June 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kenilworth 09/07/07

Kenilworth 04/08/05

Kenilworth 19/04/05

Kenilworth 06/09/04

Kenilworth 22/04/04

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Insight - Eastchurch

Southfields

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

CARE HOME ADULTS 18-65 Kenilworth (Horley) Kenilworth (Horley) 117 Balcombe Road Horley Surrey RH6 9BG Lead Inspector Pauline Long Key Unannounced Inspection 2nd June 2006 09:00 Kenilworth (Horley) DS0000013689.V294588.R02.S.doc Version 5.1 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 Kenilworth (Horley) DS0000013689.V294588.R02.S.doc Version 5.1 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. Kenilworth (Horley) DS0000013689.V294588.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Kenilworth (Horley) Address Kenilworth (Horley) 117 Balcombe Road Horley Surrey RH6 9BG 01293 784299 01293 784299 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) The Avenues Trust Limited Joanne Wood Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Kenilworth (Horley) DS0000013689.V294588.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The age/age range of the persons to be accommodated will be: 30 45 YEARS 1 Named Service user may be aged over 45 years 2 named Service users may have a sensory impairment Date of last inspection 4th August 2005 Brief Description of the Service: Kenilworth provides a home for six adults with a moderate to severe learning disability and behaviours that may be challenging. Currently there are four males and two females living at Kenilworth. The home is owned and managed by The Avenues Trust, which has a number of similar homes in the Southeast of the Country. Kenilworth is a converted two floor house situated in a residential area of Horley, within reach of the town centre with its amenities. The property has six bedrooms across both floors, with communal areas consisting of bathrooms, kitchen, dining room and lounge. There is also a large garden with a summerhouse, that has been partially converted for use as a sensory room for service users to relax in. Kenilworth (Horley) DS0000013689.V294588.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first site visit of the CSCI key inspection year and was unannounced. The inspection was carried out by one inspector and lasted for six hours. Discussions were held with the residents, relatives, a visitor to the home, acting manager and care staff. Documents sampled, included service users files, care plans, staff records, and service files and the pre-inspection questionnaire. A full tour of the home and garden took place. Verbal feedback from the resident’s at home on the day was limited, in view of their communication difficulties. CSCI would like to thank the residents, relatives, manager and staff for their hospitality and co-operation during the inspection. What the service does well: What has improved since the last inspection? Most of the requirements made following the last inspection have been met. Improvements have been made in respect of IT systems. New furniture has been bought for the garden. The oven and hob in the kitchen have been replaced. New carpet has been ordered for the main sitting room. Two new beds have been ordered. Service users opportunities for holidays have improved. Kenilworth (Horley) DS0000013689.V294588.R02.S.doc Version 5.1 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. Kenilworth (Horley) DS0000013689.V294588.R02.S.doc Version 5.1 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 Kenilworth (Horley) DS0000013689.V294588.R02.S.doc Version 5.1 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 the following standard(s): 1,2,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with the information they need to make an informed choice about where to live, however they require updating. Holistic needs assessments are completed prior to a service user being admitted to the home. Each service user is provided with a contract of the care service provided at the home. EVIDENCE: The home has developed a statement of purpose and service user guide. Each service user is issued with a service user guide, which has been developed specifically for them. It has been developed in written and pictorial format with spaces for photographs of key staff in order that service users can easily identify their key worker. Both documents require review and updating to reflect the current details of the CSCI. The home has not admitted any new service users in some time. The acting manager explained the admission process. In the first instance and following a referral, a community care needs assessment would be requested from the social and health care management teams. Once in receipt of these assessments, the home would visit the prospective service user to carry out their initial needs assessment. Prospective residents would be encouraged to visit the home prior to admission, in order to further assess their needs. Once admitted the needs assessments would be on-going. The needs assessments sampled were comprehensive and covered all aspects of daily living, indicating that staff would be aware of a service users needs. Kenilworth (Horley) DS0000013689.V294588.R02.S.doc Version 5.1 Page 9 The files sampled demonstrated that residents had been issued with a contract of the care services provided at the home. However some of them had not been signed. The acting manager stated that some of the service users would not have an understanding of what a contract was. This issue was being discussed with the organisation’s service manager and the social care management teams in order to facilitate the signing of these documents. Requirements have been made in respect of these standards. Please refer to pages 25, 26 and 27 of this report. Kenilworth (Horley) DS0000013689.V294588.R02.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Holistic care plans are in place for the service users which provide the staff with a good insight of the service users needs. Care staff enable the service users to make choices and to take responsible risks and encourage them to help in decision making at the home. Risk assessments are carried out to ensure that some aspects of safety are considered, however not all risks were assessed. Some information is not stored confidentially. EVIDENCE: The staff on duty on the day had a good understanding of the service users personal care needs. This was evident from the positive relationships observed. Care plans sampled were found to be well written, to include all daily living activities and a service users particular needs around their cultures. The care plans gave clear instructions and guidelines to the reader about a service users social and health care needs, demonstrating that the care staff would be aware of these needs. Care plans had been regularly reviewed. Some risk Kenilworth (Horley) DS0000013689.V294588.R02.S.doc Version 5.1 Page 11 assessments were in place, and clearly documented with guidelines to minimise the risks. However during the course of the site visit a service user was observed to drink from a jug, which had been left in one of the bathrooms. Whilst it was noted the jug was actually empty, there was no evidence to indicate that a risk assessment had been carried out in respect of this service users unpredictable behaviours. Discussions were had with the acting manager, around risk assessing all the areas of the home which this particular service user has access to in respect of hazardous substances, for example liquid toiletries. Staff were observed supporting service users in a respectful and unhurried manner. Choices were offered in respect of daily chores, activities, food and drinks. It was noted that information in respect of service users was kept in the homes daily dairy in the main dining room. This was viewed as poor practice as everyone entering the home would have had access to this book. Requirements were made in respect of these standards. Please refer to pages 25, 26 and 27 of this report. Kenilworth (Horley) DS0000013689.V294588.R02.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users are encouraged and enabled to maintain fulfilling lifestyles in and outside the home. The home promotes contact with family, friends and the local community. The meals offered in the home are good. EVIDENCE: The routines in the home were determined only by the timings of the visits to and from the day services, and to other appointments. During the day some of the service users had been out at various day services. On their return their body language facial expressions and the sounds they made gave the impression that they were happy to be home. The home is committed to ensuring that the service users maintain their relationships with their family and friends and the local community. The manager discussed various activities for example: arts and crafts, gym, multi centre activities, swimming, aromatherapy, horse riding and carting, visits to the shops and to the local pub. Service users also enjoy using the homes multi Kenilworth (Horley) DS0000013689.V294588.R02.S.doc Version 5.1 Page 13 sensory room. Records are kept of the various activities undertaken. However the home does not keep records in respect of daily living activities in order to provide the reader with a holistic view of a service users day. The acting manager commented that any thing untoward would be recorded. The need for keeping daily records and recording positive outcomes for service users was discussed with the acting manager. Families and friends are encouraged to visit the home, some are regular visitors and some keep contact by phone. Relatives commented that the home would always go out of their way to ensure arrangements are in place for them to visit the home. They commented that the staff were always welcoming, accommodating and that there were no restrictions on the timing of visits. Care staff commented, that service users are encouraged to choose their own menus. The acting manager explained that whilst the home has proposed menus, they are not always adhered to, depending on resident’s likes and dislikes on a given day. During the site visit a meal time activity was not observed, however the fridges and freezers were checked and found to be well stocked, with fresh meat and vegetables and other fresh food. The cupboards were well stocked with tined and dried food. Fresh fruit was available in large quanties. Relatives commented that the food at the home always looked appetizing and there was always lots of it. A requirement has been made in respect of these standards. Please refer to pages 25,26 and 27 of this report. Kenilworth (Horley) DS0000013689.V294588.R02.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff have a good understanding of the service users physical, emotional and health support needs, this was evident from the positive relationships observed. Service users are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: As discussed earlier in this report care plans included clear guidelines on any support each service user required with personal, emotional and health care needs. Relatives commented that service users health care needs were well met. It was noted that records were kept in respect of visits to the doctor, dentist and other various health related appointments. Medication procedures and practices were not observed. However all of the medication record sheets were checked and were found to be properly completed. Guidelines around “as required” medications were sampled and were found to provide clarity as to when “as required” medications could be administered and the process to be followed. Discussions were had with the care staff about the homes medication policies and procedures and they demonstrated a good understanding them. Kenilworth (Horley) DS0000013689.V294588.R02.S.doc Version 5.1 Page 15 Kenilworth (Horley) DS0000013689.V294588.R02.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has satisfactory policies and procedures in place for dealing with concerns, complaints and the protection of the residents. EVIDENCE: The CSCI have received no complaints about this home since the last inspection. Relatives commented that they were aware of the complaints procedures and if complaints are made they are dealt with in a timely manner. One referral has been made under the Surrey Multi Agency Safeguarding Adults procedures. Meetings have been held in this respect and the issue has been satisfactorily resolved. All staff have undertaken training in this respect with the exception of the most recently recruited, who has been booked on the next available course. Discussions were had with the staff on duty in respect of abuse and abusive situations and it was positive to note they demonstrated a good understanding of the current policies and procedures. Kenilworth (Horley) DS0000013689.V294588.R02.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home was reasonably clean and hygienic, however the overall standard of the environment and health and safety within some areas of the home and gardens was unsatisfactory and unsafe. EVIDENCE: Kenilworth is an older property and therefore presents challenges for the providers in respect of the ongoing need for updating repair and refurbishment. The fabric and decoration of the communal areas was on the whole unsatisfactory. The walls, ceiling and paintwork in the dining room and sitting room were somewhat soiled and chipped. Areas of the carpets were tread- bear, however the acting manager stated that the carpet in the sitting room was being replaced on the 06/06/06. The hall stairs and landing had recently been redecorated. There was evidence that the manager had requested various quotes for redecoration, however these quotes were sent to the home some time ago. The plaster on one wall in the downstairs toilet and upstairs bedroom was badly cracked and in fact had sizeable holes. The acting manager stated that this had been brought to the attention of the housing association responsible for maintaining the building and that to date they had not responded. The grouting and sealant in the upstairs bathroom was cracked and soiled. Kenilworth (Horley) DS0000013689.V294588.R02.S.doc Version 5.1 Page 18 The kitchen benefits from a new oven and hob. However attention must be paid to some of the kitchen cupboard doors, which are damaged in places and could potentially be unhygienic. Some of the service users bedrooms reflected that of any other younger adults room for example: pop posters on the walls, music centres, soft toys and several pieces of sensory equipment and were quite homely. Two bedrooms were unwelcoming, bedroom furniture was broken, there were holes in the ceiling and the walls. There was very little evidence of any personal effects in the rooms. The garden to the back of the property is very overgrown. The care staff have attempted to cut a small area of the grass, however it is unsafe. There is a small area of patio leading to the summer house, the paving slabs were uneven, causing potential trip hazards. Overall the garden does not provide a pleasant or safe environment for service users to spend time. The hard standing at the front of the property is in poor repair, there are many potholes an old water cylinder was found to propped up against a wall, all which are unsightly and more importantly could potentially present a hazard to service users, staff and visitors. One relative commented that the front of the property was dangerous and that whilst the staff do their best to maintain it, they should not have to this, and that their time should be spent caring for the service users. Attention must be paid to these areas of the home. Overall the standard of cleanliness inside the home was satisfactory. Several requiremenst were made in respect of these standards. Please refer to pages 25,26 and 27 of this report. Kenilworth (Horley) DS0000013689.V294588.R02.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,25 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for staff recruitment is satisfactory. The home employs a stable efficient, appropriately trained and supervised staff team. EVIDENCE: Two new members of staff have been recruited since the last inspection. The inspector was unable to sample these staff files as they were not kept at the home. Other files sampled evidenced that some of the required information was present, for example copies of references and job profiles. However it must be noted that there was a shortfall in respect of recruitment records. The home benefits from a stable staff team, many of whom have worked at the home since it opened, providing a consistent care service. One relative commented that staff group was more stable than in the past. The home continues to use agency staff as required but the use is minimal. The acting manager stated that in order to maintain continuity of care the home endeavours to use the same agency staff at all times. Staffing levels on the day of the site visit were adequate, with 3 care staff, and the acting manager on duty. Discussions were had with all of the staff on duty. They demonstrated that they had an awareness of their individual roles and responsibilities. Work Kenilworth (Horley) DS0000013689.V294588.R02.S.doc Version 5.1 Page 20 based observations evidenced competent and confident staff carrying out their various tasks. Staff training has improved since the last inspection, with many training courses being offered. Training records demonstrated many statutory and current good practice training had been undertaken since the last inspection, for example: managing diversity, safeguarding adults, person centred planning, health and safety, report writing, back care. Staff are undertaking National Vocation Qualifications (NVQ) some have already achieved a qualification. Relatives and visitors commented that the staff appeared to well trained and that they knew what they were doing. Improvements have been made in the formal one to one staff supervision programme in the home. Records sampled demonstrated that all care staff had received the required formal supervision meeting with a manager. A requirement has been made in respect of staff records. Please refer to pages 25,26 and 27 of this report. Kenilworth (Horley) DS0000013689.V294588.R02.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The acting manager is experienced and competent and service users benefit from her management approach. The quality assurance process must be strengthened to ensure that service users views are listened to and acted upon. The health, safety and welfare of the service users and staff is not promoted and protected. EVIDENCE: The acting manager demonstrated an open and inclusive approach and management style. From observation of her interactions with the service users and staff it was clear that there was an atmosphere of openness, understanding and respect. One member of staff commented that whilst all at the home missed the Manager and were looking forward to her return, the acting manager was very experienced and supportive. Kenilworth (Horley) DS0000013689.V294588.R02.S.doc Version 5.1 Page 22 The home sends questionnaires to the families of service users, but not to the service users. Some of the returned questionnaires were sampled and were mostly positive, one relative commented that she valued the stability and care the staff had brought to her relatives life and was very grateful for how her relative is looked after. No service users meetings are undertaken at the home. Health and safety checks are routinely carried out at the home. Records sampled evidenced that water temperatures, fire drills and fire bells were regularly checked. However it was noted that the fire extinguishers in the garden room had not been serviced since 2004. Kitchen records in respect of fridge, freezer and food temperatures were well kept. As mentioned earlier in this report there were several unsatisfactory areas around health and safety, please refer to the section of the report on the environment, standards 24 to 30. Requirements were made in respect of these standards. Please Refer to pages 25,26 and 27 of this report. Kenilworth (Horley) DS0000013689.V294588.R02.S.doc Version 5.1 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 Standard No Score 1 2 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 2 26 X 27 X 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 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 3 3 2 X X 1 X Kenilworth (Horley) DS0000013689.V294588.R02.S.doc Version 5.1 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 YA10 Regulation 12(4)(a) Requirement The registered person(s) must ensure that all documentation relating to service users is stored appropriately and confidentially. The communication book must be removed from the communal areas of the home. The registered person(s) must ensure that the matter of consent to medical treatments be considered and established for each service user. Previous timescale of 18/10/04 not met. The registered person(s) must ensure that risk assessments are carried out on all areas of the home where toiletries are kept. The risk assessments and actions to minimise the risk must be documented. The registered person(s) must ensure that all toiletries and cleaning substances are stored securely according to COSHH regulations. The laundry door and COSHH cupboard must be kept locked. The registered person(s) must ensure that all jugs are removed DS0000013689.V294588.R02.S.doc Timescale for action 03/06/06 2. YA19 12(2) 02/07/06 3. YA42YA9 13(4)(a) 09/06/06 4 YA42 13(4)(a) 03/06/06 5 YA42 13(4)(a) 03/06/06 Kenilworth (Horley) Version 5.1 Page 25 from the communal bathrooms. 6 YA24 23(2)(d) The registered person(s) must ensure that attention is paid to the decoration in all areas of the home. A plan for re-decoration must be submitted to the CSCI. The registered person(s) must ensure that all of the bedrooms have the appropriate furniture for a service users particular needs. Attention must be paid to the quality of the furniture supplied. It must be robust enough to withstand rough use. The registered person(s) must ensure that attention is paid to the garden. The grass must be cut and garden made safe for service users to enjoy. All of the paving stones must be made secure and not present potential trip hazards. The registered person(s) must ensure that the pathway from the back door into the garden is made safe in respect of the drop to the left hand side. A safety rail must be fitted. The registered person(s) must ensure that walls in the downstairs toilet and upstairs bathroom are repaired. The registered person(s) must ensure that the grouting and sealant in the bathrooms is repaired/ replaced. The registered person(s) must ensure that all of the upstairs windows have secure fittings. The registered person(s) must ensure that the area to the front of the property does not present a risk hazard to service users. The potholes must be repaired and any rubbish removed, the large water tank must be moved. The registered person(s) must DS0000013689.V294588.R02.S.doc 02/09/06 7 YA26 23(2)(d) 02/07/06 8 YA24YA42 13(4)(a) 23(2)(o) 19/06/06 9 YA42 13(4)(a) 23(2)(o) 02/07/06 10 YA24 23(2)(b) 02/08/06 11 YA24 23(2)(b) 02/08/06 12 13 YA42 YA42 13(4)(a) 13(4)(a) 23(2)(o) 19/06/06 02/08/06 14 YA42 13(4)(a) 02/07/06 Page 26 Kenilworth (Horley) Version 5.1 23(4)(c )(iv) 15 YA34 17(2) ensure that fire procedures are adhered to. The fire extinguishers in the garden room must be serviced. The registered person(s) must 02/07/06 ensure that full staff records as specified in schedule 4 Regulation 17(2) must be available for inspection. Previous timescale of 18/10/04 not met. 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. 4. Refer to Standard YA6 YA7 YA20 YA24 Good Practice Recommendations Support plans should be periodically re written, even if there are no changes to record. That consideration is given to referring those service users with limited, or no family contact to the advocacy service. (Carried forward from the previous two inspections.) That external medication training is accessed in addition to that provided by The Avenues Trust.(Carried forward from the previous two inspections.) The commission strongly recommends that consideration is made to employing a regular gardener. (Carried forward from the previous inspection.) Kenilworth (Horley) DS0000013689.V294588.R02.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Kenilworth (Horley) DS0000013689.V294588.R02.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!