Inspection on 20/03/06 for Kenneth House

This inspection was carried out on 20th March 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 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kenneth House 23/11/06

Kenneth House 30/09/05

Kenneth House 05/02/05

Kenneth House 04/06/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Kenneth House 487 Gloucester Road Horfield Bristol BS7 8UA Lead Inspector Nicky Grayburn Unannounced Inspection 20th March 2006 09:30 Kenneth House DS0000026587.V283926.R01.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 Kenneth House DS0000026587.V283926.R01.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. Kenneth House DS0000026587.V283926.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Kenneth House Address 487 Gloucester Road Horfield Bristol BS7 8UA 0117 9511082 01275 372151 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) Freeways Trust Ltd Mrs Deborah Anne Carpenter Care Home 9 Category(ies) of Learning disability (9), Learning disability over registration, with number 65 years of age (9), Mental disorder, excluding of places learning disability or dementia (2) Kenneth House DS0000026587.V283926.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Can accommodate 2 named persons of service user category `Mental Disorder` (MD) will revert to LD when persons leave. 30th September 2005 Date of last inspection Brief Description of the Service: Kenneth House is registered with the Commission for Social Care Inspection to provide accommodation and personal care for up to nine people who have a learning difficulty. The home has a condition of registration to accommodate two named people who also have mental health needs. There is also a cat that lives at the property. The house itself is situated on a busy main road and blends in well with the local surroundings. It is close to a busy shopping area, with good amenities and public transport routes. The home has a mini bus for residents use. The home is operated as part of Freeways Trust Ltd, which is a registered charity. Kenneth House DS0000026587.V283926.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was Kenneth House’s second unannounced inspection for this year. The main purpose was to follow up on previously made requirements and recommendations; check on residents’ welfare, and to ensure the premises were being well maintained. Evidence was gathered through consultation with the manager; examination of the key records and documents; talking with two residents and one member of staff, and a self-tour around the property. What the service does well: What has improved since the last inspection? A number of the requirements set at the last inspection have been met. These were mainly around meeting the health and personal care needs of residents. The medication administration has also improved and staff are more aware of having to sign the record sheets and use transfer sheets when residents spend time away from the home. The identified care plans have been reviewed ensuring that residents’ needs are better met. The home has started piloting a health care plan with one resident and depending on how it goes; they will be used for all of the residents. The manager has also updated the home’s Statement of Purpose, which describes the home’s philosophy and services. Kenneth House DS0000026587.V283926.R01.S.doc Version 5.1 Page 6 Two requirements regarding the environment has been met, the garden is now a more pleasant and safe area, and a resident’s bedroom flooring has been replaced making the room much nicer. The manager has a new deputy who is still settling into the role, but is keen to progress and support the residents and manager. There is now only one parttime vacancy to complete the team. 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. Kenneth House DS0000026587.V283926.R01.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 Kenneth House DS0000026587.V283926.R01.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 A revised statement of purpose enables prospective residents to decide whether Kenneth House will meet their needs. Residents would benefit from an up-to-date contract to ensure that they know what they can expect from the home. EVIDENCE: There have been no new residents since the previous inspection. There are no vacancies within the home for prospective residents. The statement of purpose was an outstanding requirement from the preceding inspection. It had not been done within the timescale but the manager has now completed this but it has not yet been circulated to staff or residents. A copy of the document was delivered to The Commission for Social Care Inspection. Residents and staff must have access to this document. There were two new residents at the last inspection and a requirement was made to ensure that they both have a care plan and a needs assessment. This is now in place. One resident had had their latest review last week, and another was taking place that week. A previously made requirement was for all residents to have an up-to-date contract of terms and conditions. This has not yet been completed but the manager has the paperwork in preparation. These are user-friendly and are now a standard document within Freeways. The requirement remains. Kenneth House DS0000026587.V283926.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 8, 9, 10 Residents are consulted on aspects of the home and their changing needs are assessed and reflected in their individual plans. Residents would be better supported if the risks taken are thoroughly assessed. EVIDENCE: As noted from the monthly provider reports and through discussion with the manager, risk assessments are needed for some manual handling tasks. The manager is writing these and will send an example copy to the inspector. There were no risk assessments present in either of the two files looked at. This will be a focus of the next inspection. Care plan reviews are held regularly to ensure that the residents’ needs are assessed in a formal capacity. Residents also have a ‘Listen to Me’ book, which is being worked through with their individual key worker. On the notice board, and a resident confirmed that there are regular house meetings to address issues such as ‘house jobs; Easter; activities’. Each resident has a ‘Life Skills Day’ when they are supported by staff to carry out their household duties such as their laundry and cleaning their bedrooms. Kenneth House DS0000026587.V283926.R01.S.doc Version 5.1 Page 10 A requirement had been made to ensure that residents know that information about them is handled appropriately. This has not been fully met. The manager has obtained four more keys to the filing cabinet containing residents’ personal information to aid access rather than keeping them open. This standard was further discussed with the manager and she will be raising the issue in the next staff and residents’ meetings. It was also advised that a record of who has access to the information be presented to individual residents (where appropriate) to ensure that they are fully aware. This will be followed up at the next inspection. Kenneth House DS0000026587.V283926.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15, 16, 17 Residents have opportunities for personal development within the local community and access activities outside of the home. Residents are supported to maintain relationships with their supporters. A healthy diet is offered to residents and they enjoy mealtimes. EVIDENCE: It was evident from the notice board signs and from talking with residents that there are a good choice of activities that residents can choose to participate in. Some residents go out in the evenings, for example to the pub to play darts, and go to a local disco. There is a pictorial weekday activities matrix with photos of the residents. Over the Christmas period, some residents stayed with relatives. One resident told the inspector that it was the first Christmas they ever enjoyed. Kenneth House DS0000026587.V283926.R01.S.doc Version 5.1 Page 12 Many of the residents attend day centres and college courses. Certificates around the home and in individual’s bedrooms showed that residents participate in their personal development. Two residents showed the inspector their recent achievements and were very proud of them. Due to the range of needs presented by the residents, annual holidays are taken throughout the year to enable more intensive support by staff. Some residents are involved with ‘People First’, which is an advocacy service for people with learning difficulties. A resident spoke to the inspector about this and how they enjoy going there and were aware that they can get help through this service. One resident had recently been in the local paper raising awareness of the state of the pavements on the main road for people who use a wheelchair. Through discussion with two residents, it was evident that relationships with family and friends are maintained and supported. Residents spoke positively about their time visiting relations for holidays and over weekends. In residents’ bedrooms, there are many photos of the resident with family and friends. Residents told the inspector of particular friends they have within the home. It was evident throughout the inspection that staff interact with residents positively. Residents have unrestricted access to the shared spaces and some hold keys to their bedrooms. A resident spoke fondly of meal times sat around the dining room table. If they don’t like the evening meal the alternative is a sandwich. It is recommended that another hot meal be offered to ensure that residents receive a healthy diet and that it fully meets this standard. The menu was looked at and offers a wholesome and varied diet, but does not state an alternative meal choice. Kenneth House DS0000026587.V283926.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21 Residents’ health needs are met. Residents are protected by the home’s medication system. Residents would benefit and be assured if the home was aware of their wishes in the event of death. EVIDENCE: Each resident has a key worker who writes a monthly report. These include room checks and health checks to keep track of appointments. A requirement was made to involve the residents in their health care plans. The manager confirmed that the home is piloting one with a particular resident, and she has devised a new record with a space for the resident to sign. One resident is displaying changing needs. The staff and manager are very aware of this and have approached their funding authority for an increase of funding for staffing. Other professionals are also involved to help the resident. Music therapy had been arranged for the following week. Following a previously made requirement regarding dentistry, the manager informed the inspector that the newer residents had continued to use the same dentist from their previous home. There was no evidence during the previous visit; however, both residents have visited their dentist since. Kenneth House DS0000026587.V283926.R01.S.doc Version 5.1 Page 14 Staff support residents with these appointments. An example of this was discussed with the manager due to the increased need for one resident to receive treatment. The medication administration was inspected fully at the previous inspection, with an arising requirement for transfer sheets to be used when residents go away, and for staff to remember to sign the medication administration record sheets. The manager confirmed that transfer sheets are always used now and that despite there still being some errors, there has been an improvement. The staff meeting minutes and communication book evidences that this issue is being addressed. The member of staff also confirmed the training staff receive and was aware of procedures concerning errors. The manager confirmed that a few residents now have records of their wishes in the event of their death. However, the requirement has not entirely been met, and records were not found in the files looked at. This was discussed with the manager and how some residents did not wish to discuss this and how families will be involved. The requirement remains. Kenneth House DS0000026587.V283926.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Residents are protected from abuse and concerns are listened to. Residents would further benefit from having a clear procedure regarding complaints. EVIDENCE: There have been no formal complaints made since the last inspection. The requirement regarding the last complaint had been investigated and concluded. There is a clear written and pictorial complaints procedure on the resident’s notice board. However, as previously required, it needs to state the timescales in which residents can expect a formal response. This was an outstanding requirement from the earlier inspection and this was discussed with the manager, who assured the inspector that she will be adding this to the format. The requirement remains. Further, it was required for residents to be aware of the procedure, as it is apparent from discussions with residents that they were unaware of this. It was evident from a residents’ meeting’s minutes that the procedure was discussed and a resident confirmed with the inspector what they would do and that they are comfortable with raising issues with the manager. Protecting vulnerable adults was a subject during the home’s recent ‘Team Away Day’. Staff receive training updates from the manager, and a different manager from another of Freeways Home will take the next training session. It is recommended that the manager undertakes the training provided for managers to ensure that she also receives current practice updates. It was also noted in a staff’s file that there was no evidence to show that they had any training in this area. The manager must ensure that they receive this training within their induction period. Kenneth House DS0000026587.V283926.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30 Residents’ bedrooms and bathrooms meet their needs, and shared spaces complement the number of residents. The home would benefit from being more hygienic and having aids appropriately placed to maximise residents’ independence. Residents live in a homely environment. EVIDENCE: Kenneth House is a homely and comfortable environment. It was observed how residents could access all shared areas throughout the day. There is a small front garden and a larger back garden with a seating area. The refuse, which was required to be removed, had been done thus improving the health and safety for the residents. The manager told the inspector of the future building work to the lower area, which will improve storage space. Five bedrooms were viewed and all were found to be personalised and represented the resident’s interests and hobbies. A requirement was made regarding one resident’s carpet, which has been met. The room was redecorated and looks much nicer. Kenneth House DS0000026587.V283926.R01.S.doc Version 5.1 Page 17 One identified bedroom’s floor has large areas of visible rust under the bed’s frame. This was immediately brought to the attention of the manager who said that they would try to clean it off immediately. If that doesn’t work, it must be replaced. Staff must ensure that they dry the floor after cleaning it to prevent rust from building up. At the last inspection, a resident told, and showed the inspector that they did not have any storage or shelving space for their personal affects. The resident showed the inspector their room again and the requirement has been partly met. Residents are to be provided with somewhere to hang coats and dressing gowns rather than on the open wardrobe door, which could be deemed as a health and safety issue due to the weight hinging on the doors. It was recommended that the shower room’s tile grouting should be deep cleaned or replaced. This has not occurred and has worsened. The manager said that it was supposed to have been done in February, but was not, and there was no reason for it. It is now a requirement. The other toilets and bathrooms were clean and in good condition. There is one bedroom on the ground floor for a resident with mobility difficulties. Some other residents have mobility difficulties, which are stated in their care plans and risk assessments, and some had told this to the inspector during the previous visit. A requirement was made at the last inspection for an additional banister to be fitted to aid independence and use of the stairs. This has not yet been done. The manager confirmed that the occupational therapist has visited to confirm the need. The hold up has been due to the issue of funding. Further, a check on the wall’s strength is needed. The manager further confirmed that the banister will run all the way up to the top floor and the work is planned for the imminent future. The requirement remains. The stair’s carpet is stained and worn. It is recommended that the carpet be replaced. The kitchen is starting to look jaded. The surfaces were clean. However, it was brought to the attention of the manager that the floor was not clean; that the corners and near some white goods there were large build-ups of grime, and the insides of most of the cupboards were dirty and need to be cleaned thoroughly. There was a rota in the office of the cleaning duties. This must be adhered to, to prevent the spread of bacteria and to maintain a hygienic home. Further, some of the cupboard doors are loose and could cause injury. It is required for these to be repaired or replaced. Kenneth House DS0000026587.V283926.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 Residents are protected by the home’s recruitment practices and a competent staff team supports them. Residents would benefit further by having a well supervised staff team. EVIDENCE: There is stable group of staff who work at Kenneth House. At present there is one part time post vacancy. The full time vacancy has been filled and the home is awaiting satisfactory receipt of the relevant documents. A new deputy manager has been in post for four months and already knew some of the residents from previously working at the day centre run by Freeways. The staff file was examined and contained the relevant documentation. Two supervision notes were also on file evidencing specific training and development needs. Staff undertake the Learning Disability Assessment Framework and then continue onto the NVQ in care. The manager gave details of the individual staff and their progress. Some staff refuse to undertake training which is not mandatory which may hinder their ability to support some residents with specific needs. One member of staff told the inspector that they felt that there was good staff morale within the house and at training days. Kenneth House DS0000026587.V283926.R01.S.doc Version 5.1 Page 19 The manager said that supervision levels have nearly resumed to their recommended frequency. It was reported in the monthly provider report that some supervisions were overdue. It was discussed with the manager about certain staffing issues and how staff stay on probationary periods until satisfactory levels of good practice are attained. The bank member of staff said that they do receive supervision, but is due one. The manager must ensure that staff receive regular supervision. Kenneth House DS0000026587.V283926.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42 Residents are protected by the home’s health and safety system. Residents would benefit from a robust quality assurance system and from a better run home. EVIDENCE: The manager was present during the inspection and was aware of all the issues raised regarding the outstanding requirements. Debbie Carpenter has been the registered manager since April 2003. She is the sole LDAF assessor within Freeways and conducts training for support staff such as dementia, and loss and bereavement. Mrs Carpenter holds Stage one in Further Adult Education Teacher’s Certificate. It was disappointing that many requirements remain outstanding, and enforcement action will be considered if they are not actioned within the newly set timescales. If requirements remain unmet this also reflects the managers fitness and ability to manage. Kenneth House DS0000026587.V283926.R01.S.doc Version 5.1 Page 21 A requirement made at the last inspection was regarding a formal quality assurance system. This has not been met. Freeways, as an organisation, are devising a system for all of its homes ready for use in April 2006. The home does hold resident’s meetings; staff meetings; and has an open-door atmosphere within the home. The provider monthly reports are carried out; sent to the Commission for Social Care Inspection, and are very informative. However, the requirement remains. The home has improved its monitoring system for health and safety issues. All relevant checks on fire protection systems are carried out within the relevant timescales. Electricians were at the home during the visit carrying out the five yearly test of the home’s system. The previous requirement concerning Standard 42 has been met; the gas safety certificate is now on the premises and the appliances and heating system was checked 21/7/5, and the Portable Appliance Testing (electrical equipment) was checked 7/12/5. There is also a pictorial ‘fire plan’ on the notice board. The last recorded fire drill was 24/11/05 in the evening. The manager showed the inspector the assessments and COSHH information for the products kept in the house during the visit. Residents do not have access to the products and carry out their ‘house jobs’ with support from staff. Kenneth House DS0000026587.V283926.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 1 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 2 27 2 28 3 29 2 30 1 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X 3 2 2 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 3 2 2 X 2 X X 3 X Kenneth House DS0000026587.V283926.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? YES 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 YA5 Regulation 5 (a)(c) Requirement The manager to develop and agree with each resident a written and costed contract of terms and conditions between Kenneth House and the resident. (Outstanding requirement, previous timescale 30/11/05) Timescale for action 21/04/06 2. YA10 12 (3) Staff to ensure residents know that information about them is handled appropriately. 07/04/06 (Outstanding requirement, previous timescale 30/11/05) 3. YA21 12 (2)(3) Consult with residents about their wishes in the event of their death. (Outstanding requirement, previous timescale 21/11/05) 30/04/06 4. YA22 22 (4) Complaints procedure to be updated to include timescales. (Outstanding from previous previous inspection 5/4/5) 31/03/06 5. 6. YA24 YA26 23(2b) 23 (2m) The kitchen cupboards to be repaired or replaced. Residents to be provided with adequate storage space. 30/04/06 07/04/06 (Outstanding requirement, previous timescale 11/11/05) 7. YA27 23(2b,d) Shower room’s tile grouting to DS0000026587.V283926.R01.S.doc 30/04/06 Page 24 Kenneth House Version 5.1 be deep cleaned or replaced. 8. YA29 23 (2a,n) (Outstanding requirement, previous timescale 31/01/06) Banister is fitted to staircase 30/04/06 9. YA30 23(2d) 10. 11. YA36 YA39 18(2) 24 a) The kitchen floor to be deep cleaned. b) The inside of the cupboards to be cleaned thoroughly. c) Clean the rust or replace the flooring in the identified bedroom. Staff to receive regular and appropriate supervision from their line manager. A quality assurance system to be in place for residents to underpin the development of the home. (Outstanding requirement, previous timescale 21/11/05) 07/04/06 30/04/06 30/04/06 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 YA17 YA23 YA24 Good Practice Recommendations An alternative hot meal is offered. The manager to undertake ‘Safeguarding Adults for Managers’ training. Stairs carpet be replaced. Kenneth House DS0000026587.V283926.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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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