Inspection on 05/10/05 for Khaya Project

This inspection was carried out on 5th October 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Khaya Project 23/11/06

Khaya Project 20/02/06

Khaya Project 03/03/05

Khaya Project 29/07/04

Khaya Project 24/02/04

Khaya Project 09/09/03

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

CARE HOME ADULTS 18-65 Khaya Project 71 Wellesley Road Ilford Essex IG1 4LJ Lead Inspector Stanley Phipps Unannounced Inspection 5 October 2005 11:30 Khaya Project DS0000037133.V255299.R01.S.doc Version 5.0 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 Khaya Project DS0000037133.V255299.R01.S.doc Version 5.0 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. Khaya Project DS0000037133.V255299.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Khaya Project Address 71 Wellesley Road Ilford Essex IG1 4LJ 020 8554 7902 020 8554 7902 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) Mr Ndumiso Mafu Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Khaya Project DS0000037133.V255299.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. A minimum of 2 staff on duty at all times. Unless residents are not on the premises. The rota to include designated time each week, supernumary to the miniumum 2 staff, for Mr Mafu to operate in his roles as proprietor and manager. There must be two staff on night-waking duty at all times, as there are no sleeping-in facilities currently in the home. 3rd March 2005 Date of last inspection Brief Description of the Service: Khaya Project is a care home providing personal care and accommodation for five people ages 18 – 55 with a history of mental illness, who need support in order to live in the community. It is privately owned and run by Mr Ndumiso Mafu. The home is located in Ilford approximately 5-10 minutes from Ilford British Rail station and town centre and as such lends itself to all the amenities contained therein. These include a wide range of shops, pubs, the post office, entertainment centres, parks and library facilities. The home was opened in 2003 and is an ex-residential property built on two floors, which was refurbished in order to set up this service. There are bedrooms and communal rooms on both floors and staff would be expected to work closely supporting service users. The registered manager successfully applied for a variation in the summer 2004 to increase the number of beds from four to five. He has since added a conservatory that is spacious and contains a music centre for the enjoyment of service users. All the home’s bedrooms are single, and one of the five has en-suite facilities. Access between the floors is via two sets of stairs. The home has a large rear garden part of which is intended for gardening with the other for leisure. The leisure area is satisfactorily maintained and the garden is in the process of being developed. Khaya Project DS0000037133.V255299.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place in just over three hours and was timed to coincide with meeting service users, observing daytime activities and lunch, and to monitor the service. The inspection found that improvements to the service are on the increase when compared to the last inspection visit and that the registered manager is committed to ensuring full compliance with the national minimum standards for younger adults. To this end the previous requirement was satisfied and service users spoken to were generally happy with the services provided at the Khaya Project. All service users looked relaxed on the day and one commented - ‘we live like a family here’. This was positive comment and it reflected the overall ethos of the service. Discussions were held with four service users, two members of staff and the manager. A random sample of care plans, policies and procedures, medication, health and safety and recruitment records were examined, followed by a tour of the environment. What the service does well: What has improved since the last inspection? Broken floor tiles have been replaced on the first floor and this not only looks good, but is safer for both the staff and service users. The manager has been proactive in organising his staffing supervision well in advance e.g. February 2006. This means that staff have more than ample notice, but also it reinforces Khaya Project DS0000037133.V255299.R01.S.doc Version 5.0 Page 6 the fact that staff supervision is an integral part of supporting staff and providing a good quality service. 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. Khaya Project DS0000037133.V255299.R01.S.doc Version 5.0 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 Khaya Project DS0000037133.V255299.R01.S.doc Version 5.0 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): (1,2,3,4 &5) Prospective service users have at their disposal information that enables them to make an informed decision as to whether the Khaya Project is appropriate for them. This is enhanced by the pre-arranged visits to the home, prior to admission, in order to get a feel of how things are done. They also have the peace of mind in not only knowing what is offered in the home’s statement of purpose, but also in a statement of terms and conditions, that is given to each individual. EVIDENCE: The manager has reviewed and updated the home’s statement of purpose in line with the requirements of the Care Homes Regulations 2001. It was noted that there were no changes to the service structure. At the time of the visit a prospective service user was in the process of being assessed to move into the home. In conversation with service users he had visited the home to determine its suitability with regard to meeting his needs and this was a normal part of the admission process. On examination of a sample of service user files, there was evidence of contracts in place for each of them, which contained obligations of both the provider and the service user. Both parties signed the document, once the placement has been agreed, and this arrangement was satisfactory in that service users are very much involved in the process. Service user files also bore evidence of needs’ assessments conducted on individual service users from which their service user plans are developed. These plans are then used to carry out individual work with service users. Khaya Project DS0000037133.V255299.R01.S.doc Version 5.0 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) The needs of service users are well documented in their individual service user plans, which are reviewed as changes occur. Service users are involved in negotiating their daily routines and objectives and are empowered through the risk management strategies of the home. EVIDENCE: From a random sample of service user plans that were examined, it was clear that the manager and staff were working closely with service users in determining their needs. Once the needs are assessed, a service user plan is formulated with the service user’s involvement and this is usually carried out with the individual’s key-worker. In discussion with a service user he spoke of his key–worker stating that he (the key-worker) helps to sort his life out, giving examples like, going to his health appointments and keeping his room tidy. The needs assessment detailed aspects of health, personal, social and special needs e.g. mental health. Service users also confirmed that they were involved in decision-making in the home through their service user meetings, key-work sessions and informally. Two service users informed that they are involved in determining leisure activities, meals, in-house entertainment and their individual pursuits. For example one service user enjoys doing weights, so he is supported to his Khaya Project DS0000037133.V255299.R01.S.doc Version 5.0 Page 10 weight training in the privacy of his room and is very motivated by the results he gets out of the activity. This is really positive. Risk assessments were examined and were up to date and it was observed in one case that a decision was taken to support a service user to budget his finances. Although most service users prefer to handle their own finances, it was agreed through the risk management framework that the service user is given agreed daily amounts to meet his needs. This approach promoted both learning and development for the service user concerned. Another good example of risk taking in promoting service user’s independence at Khaya involved one service user who enjoys going out, but has the tendency to stay longer than indicated. This occurs frequently and evidence was available to support the fact that multi-disciplinary reviews, debriefing meetings, triggermapping and risk reviews were undertaken to reduce the risk of the service user coming into harm. In essence the service user still goes out visiting, but clear guidance was in place, should he be away longer than planned. From speaking with staff and the manager it was determined that the service user had been actually making marginal, but significant progress since his arrival at Khaya. Khaya Project DS0000037133.V255299.R01.S.doc Version 5.0 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): (15,16,17) Service users at the Khaya Project have opportunities to develop and maintain social and personal networks of their choosing. This gives them something invaluable to look forward to, living in the community. Staff work in a dignified manner with them and all service users feel empowered by this. Meals are satisfactory in content, varied and reflective of service users’ cultural needs. EVIDENCE: Staff work closely with service users and their relatives in order to maintain a healthy network of relationships. Though there are varying levels of involvement depending on the individual service user, these networks are the choices made by them. One service user visits his mother regularly, while another’s parents visit him occasionally, but is in telephone contact with him and this was described as a two-way arrangement i.e. the service user calls up as well. Records indicated that relatives are involved in various aspects e.g. socially or in the promotion of the service user’s health and welfare at the Khaya Project. Up to two service users indicated that they have friends of their own, while one indicated that he prefers being by himself, but sees his colleagues in the home as his mates anyway. Khaya Project DS0000037133.V255299.R01.S.doc Version 5.0 Page 12 Service users have individual programmes and up to three of them confirmed that their rights were not only promoted, but respected by the manager and staff of the home. They all had individual responsibilities for taking an active part in individual programmes drawn up with them in their interest e.g. one individual meeting every two weeks with his with his social worker and community psychiatric nurse, then attending a day centre in Bethnal Green that provides a service for individuals from an Afro-Caribbean background and taking responsibility for maintaining the cleanliness of his private room. This service user indicated that he fully recognises the importance of participating in his programme, but he didn’t feel pressured to do it, as the staff are flexible and enabling. This is also positive. Lunch was observed on the day and it was off-menu i.e. service users wanted something different to what they had previously agreed. The meal was varied, well presented and served in quantities that were appropriate to the individual needs (e.g. one service user was working on his weight, so he opted for a smaller portion) and choice of individual service users. Service users were able to eat wherever they chose and when they were ready, so the home did not feel institutional. All service users commented positively on the quality of the food on the day as well as meals in the past. Records of meals consumed were reflective of choice, but also culture and preference. The service user group is mixed i.e. white British and several from a minority ethnic grouping e.g. AfroCaribbean and the record of meals indicated that cultural preferences were catered for. At least one service user is empowered to prepare a meal for himself, which is supported by staff and this is also positive. Khaya Project DS0000037133.V255299.R01.S.doc Version 5.0 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) Sound arrangements are in place for monitoring the healthcare needs of service users, in the promotion of their health and welfare. They are encouraged to take responsibility for their health and although this is achieved at various levels, it is a positive experience for all service users at the Khaya Project. Satisfactory arrangements were also in place should a service user die in the home. EVIDENCE: The skills of staff were on display as they successfully supported a service user to attend to his appointment for investigations into his health. Throughout the interaction the respect, dignity and choice of the service user was maintained and this was positive. From the records viewed there was evidence that the physical and emotional health needs of service users were provided for e.g. optician, chiropody, GP and psychiatric. There was evidence that service users are appropriately supported with their medication which is an integral part of managing their symptoms. This has a positive impact on their well-being and thus they are able to lead fairly normal lives within the context of their illness. At the time of the visit one service user was self-medicating and he was really proud and positive about this. He felt more in control of his life and was grateful for the staff and managers input in Khaya Project DS0000037133.V255299.R01.S.doc Version 5.0 Page 14 achieving such a milestone. This is an excellent outcome and all service users have a similar opportunity following a detailed assessment and risk assessment. Service user records also contained evidence of key work sessions held with service users for various reasons e.g. medication, unhappiness about care or how they are coping in the home. Service users spoken to knew their key workers and confirmed that meeting with them was useful. A death and dying policy is in place at the home and staff interviewed showed an awareness of preserving the dignity of a service user should they pass away in the home. There have been no deaths in the home. A score of four (4) has been awarded to the standard relating to medication (NMS 20) for the significant achievement in supporting a service user to selfmedicate as part of the medication management in the home. Khaya Project DS0000037133.V255299.R01.S.doc Version 5.0 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) At the Khaya Project service users and their relatives can feel reassured that concerns, when raised, would be taken seriously through a timely and thorough investigation, which is in line with the home’s complaint’s procedure. EVIDENCE: An active and comprehensive complaint’s procedure is in place and this is well advertised in the home. As a matter of course service users and/or relatives are encouraged to talk about issues they may have a concern with. This allows the management and staff an opportunity to make early interventions to reduce the risk of problems arising. One of the key forums used is the service users’ meeting, where issues like annual holidays and health and safety matters are raised and dealt with. Staff interviewed were comfortable with supporting service users who may wish to complain. Service users were also happy with the fact that they feel able to complain to the staff and manager if they were unhappy or uncomfortable with anything. There were no complaints since the last inspection. Khaya Project DS0000037133.V255299.R01.S.doc Version 5.0 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): (24,25,27,28) Service users enjoy a clean, homely and comfortable environment when residing at the Khaya Project and this is viewed positively and appreciated by all. Adequate toilets and bathrooms compliment the rest of the environment at the Khaya Project, although closer checks could be made on bathroom fittings to ensure that they are safe. EVIDENCE: There is homely and airy feel to the home upon entering the front door, as the environment was clean and well presented. Service users were seen using various aspects of the home in a comfortable manner and they were very pleased with the overall décor of the home. One service user showed off his bedroom and this was in a good state of repair and decorated to suit his lifestyle and personal taste. Other service users spoken to expressed their satisfaction with their own bedroom. The recently constructed conservatory gave the home a rich feel and all service users were quite pleased with it as they had a choice of watching television, listening to music or chatting in separate rooms. Three service users expressed their satisfaction with the home indicating that they lived like a family there. In speaking with one service user, he informed that another service user was due to come and he was introduced to him, which he thinks is a good idea as they would not want someone to Khaya Project DS0000037133.V255299.R01.S.doc Version 5.0 Page 17 come in and unsettle the home. The service user spoke as though he knew of his stake in the home. Toilets and bathrooms remain adequate for the numbers and needs of the service user group and they were clean and generally satisfactorily maintained. However it was observed that the shower hose in the main bathroom had deteriorated in that the outer metallic housing had lost it contours, making it possible for the inner plastic housing to be caught in the grooves of the metal housing. This would interfere with the hot/cold mix and produce a poor flow. This must be changed and it was pointed out to the registered manager. Khaya Project DS0000037133.V255299.R01.S.doc Version 5.0 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): (31,34,35,36) Service users at The Khaya Project benefit from having a dedicated and wellsupported staff team who work well together to enhance the quality of services they receive. The recruitment strategy of the home is robust and offers protection to the service user group. EVIDENCE: Staff were interviewed and observed during their practice on the day of the visit. They carried out their responsibilities with a calm, but confident demeanour which was reassuring not only to the service users, but to the inspector as well. They were fully aware of the needs of the service users in the home and worked flexibly with them to support them in achieving their objectives. From talking to a service user he spoke of his reluctance to comply with both his dietary and health care goals. He advised that his key worker and the manager spent a lot of time talking to him about the dangers and advantages of him taking more positive action regarding his physical health and eating habits. This resulted in him taking up a health appointment for investigations supported by one of the staff on the day of the visit. It was clear that the service user had all the information he required to make a positive choice, which he did in the end. Assessing the case records of service users it was clear that individual and collective needs of service users were adequately met by well-trained staff. Up to seven of the care staff had training up to an NVQ level 3 standard and this exceeded the minimum requirement, which was to achieve a fifty per cent quota at NVQ level 2. Khaya Project DS0000037133.V255299.R01.S.doc Version 5.0 Page 19 There was clear evidence that staff were adequately supervised as records and information received from staff confirmed this. As a matter of fact staff supervision was scheduled right through till February 2006. Staff were also briefed through regular staff meetings and informal daily handovers. It was concluded that excellent arrangements were in place to enable staff to carry out their responsibilities safely with service users. Looking at the recruitment records of staff, it was observed that all necessary checks were undertaken on staff before the commencement of employment. References were satisfactory and application forms were filled out in detail. The recruitment practices undertaken by the manager were robust and in line with the employment policies of the organisation. The ethnic mix of the staff complement was raised with the manager, as the current mix indicated an overwhelming slant towards a minority grouping. A copy of a recent advert was examined as the manager gave the assurance that there was a problem attracting staff from the mainstream population. Although it is a fact that minority ethnic people are overrepresented in the mental health system, there is a substantial number of service users from the mainstream cultures also in receipt of psychiatric care and support. As stated earlier the population of the home is mixed, but the manager advised that he would keep trying to recruit from the mainstream culture, which is Caucasian. Scores of 4 have been awarded in relation to Standards 35 and 36 Khaya Project DS0000037133.V255299.R01.S.doc Version 5.0 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): (37,40,41,42,43) There are sound management systems in place to enable service users to receive a high standard of care at the Khaya Project. An experienced manager leads a staff team that is willing and committed to working with the service user group in promoting their welfare. EVIDENCE: The daily management of the home is sound and both service users and staff confirmed this. They felt that the manager was easily available to them for support and guidance and it was observed that he (the manager) has a very good rapport with both groups. It was also very clear that he leads from the front and knew in detail of the needs of each individual service user, as well as prospective service users. Sound evidence was in place to confirm that regular staff meetings are held i.e. on a monthly basis and they are very detailed covering all aspects of the service. This is positive as staff are not only wellinformed, but also make significant contributions to the service itself at these meetings. Khaya Project DS0000037133.V255299.R01.S.doc Version 5.0 Page 21 An examination of the policies and procedures found that they were updated and accessible to all staff. Records were also updated and maintained in line with regulatory requirements, thus providing a safety net for service users. Health and safety practice in the home was generally satisfactory and this included regular fire drills and call point testing. There was also evidence of portable appliance testing being done as recently as the 4/10/05 and a faulty cooker hood was replaced on the same day. The registered manager clearly demonstrated that safety of service users and staff was a priority in his management of the service. A professional accountant audits the accounts of the home and it was disclosed that the home was financially viable. Insurance cover was in place and met with the statutory requirements. Therefore service users are reassured that their placement at the Khaya Project is secure, from a financial point of view and this adds to their peace of mind and stability. Khaya Project DS0000037133.V255299.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 X 2 3 X x LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 X X 3 4 4 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Khaya Project Score X 3 4 3 Standard No 37 38 39 40 41 42 43 Score 3 X X 3 3 3 3 DS0000037133.V255299.R01.S.doc Version 5.0 Page 23 NO 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 YA 27 Regulation 13 Requirement The registered manager is required to replace the hose in the shower attachment of the main bath. Timescale for action 18/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Khaya Project DS0000037133.V255299.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Khaya Project DS0000037133.V255299.R01.S.doc Version 5.0 Page 25 - 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. 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