Inspection on 07/09/05 for Pathways

This inspection was carried out on 7th September 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pathways 30/08/07

Pathways 09/08/06

Pathways 07/03/06

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 No 11 Pathways 11 Gloucester Drive Hackney London N4 2LE Lead Inspector Kristen Judd Unannounced Inspection 7 September 2005 at 10:10am th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. No 11 Pathways G56 G06 S65292 No 11 Pathways V248549 070905 Stage 41.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service No 11 Pathways Address 11 Gloucester Drive, Hackney, London, N4 2LE Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8860 2619 020 8862 6862 graham@pathwayscare.net Care Support Service Ltd trading as `Pathways` Ms Joanna Mary Brunt Care Home 8 Category(ies) of Learning disability (8) registration, with number of places No 11 Pathways G56 G06 S65292 No 11 Pathways V248549 070905 Stage 41.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th February 2005 Brief Description of the Service: 11 Gloucester Rd is registered with the Commission for Social Care Inspection to provide care and accommodation for eight young adults who have learning disabilities and was registered in July 2004.From 27th July 2005 the home is known as Pathways. The home is a quite residential road in Frinsbury Park area of the London Borough of Hackney and is well positioned to access a range of community amenities, local parks and transport links. The aim of the home is to provide a specialised service in working with service users with complex needs, in particular challenging behaviour and autism. It is a large house on four floors which provides adequate communal areas. There is a small courtyard area. At the time of inspection there were five service users placed. No 11 Pathways G56 G06 S65292 No 11 Pathways V248549 070905 Stage 41.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced which started at 10.10 am until 3.10 pm. This inspection followed up the requirements made at the unannounced visit held on 28th February 2005. The inspector spoke with two service users, staff and the registered manager during the inspection. A tour of the environment was undertaken and samples of the homes records were examined. There were five service users placed at the time of inspection with a new admission planned. There have been 13 requirements and 1 recommendation made following this inspection. Verbal feedback was given to the registered manager at the end of the inspection. The inspector wishes to thank the staff and service users for facilitating this unannounced inspection and actively contributing to the regulatory process. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. No 11 Pathways G56 G06 S65292 No 11 Pathways V248549 070905 Stage 41.doc Version 1.40 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection No 11 Pathways G56 G06 S65292 No 11 Pathways V248549 070905 Stage 41.doc Version 1.40 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3&4 It is the inspector’s view that that a thorough process is undertaken prior to the admission of new service users to ensure that their needs can be met. EVIDENCE: The residents’ service user guide has been developed; the guide is nicely presented in a service user-friendly format ,the guide does includes a copy of the pictorial complaint procedure. Comprehensive assessments are completed prior to service users being admitted to the home. The assessments seen were comprehensive and specific to the needs of the service user. Prospective service users have an opportunity to visit and ensure the home is suitable to their individual needs. Prospective service users have a three-month trial settling in period, prior to deciding if they wish to live permanently in the home. The inspector noted that a service user is at present undergoing an assessment. The registered manager was in the process of developing the service users file, which contained relevant information. Members of the staff team had made several visits to the prospective service user at home and written reports were seen, these evidenced the interaction between staff and the service user. No 11 Pathways G56 G06 S65292 No 11 Pathways V248549 070905 Stage 41.doc Version 1.40 Page 8 The inspector was informed that the next stage was for the service user to spend time at the home interacting with current service users prior to admission. This would over a period of some weeks. The registered manager was able to discuss and demonstrate how the complex needs of the prospective service user were to be met. It was evident that much work had been done to ensure that the environment was suitable to meet the individual’s needs. Through discussion, the inspector was satisfied that the registered manager was able to demonstrate that the home has the capacity to meet the service users’ needs. Evidence was seen during the inspection that confirmed that the registered manager liaises closely with health professionals with regard to accessing specialised services in relation to learning disability. No 11 Pathways G56 G06 S65292 No 11 Pathways V248549 070905 Stage 41.doc Version 1.40 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 standard(s) 6,9 &10 The inspector believes that service users needs are being met by staff. However all of the service users needs must be reflected in the individual service users plans and be supported by comprehensive risk assessments to ensure that service users are not put at undue risk. EVIDENCE: Care plans examined contained some information about the service users daily routines, personal care and daily living issues in addition to behavioural issues and guidelines for dealing with individual service users. However through cross-tracking of relevant information it was noted that risk assessments and care plans did not highlight all of the service users needs. It was noted that one service user was prone to self-harming however this was not indicated on the care plan. In addition some of the individual needs on the care plan had not been fully completed in particular with regards to in continence and epilepsy. The service user has been placed at the home since June and as such the care plan should be complete. Additionally risks that were clearly noted on guidelines when working with the service users had not been risk assessed. For example one-service user records indicated that the service user might put a razor into their mouth if No 11 Pathways G56 G06 S65292 No 11 Pathways V248549 070905 Stage 41.doc Version 1.40 Page 10 accessible however no risk assessment was in place and no information was on the individual care plan. However it is noted that staff and the registered manager spoke knowledgably about the individual needs of the service users. The interaction between service users and staff was observed as being very positive and sensitive to their needs. During the inspection there was an incident at the home staff were able to discuss with the inspector the issues and their individual response. Reactions were deemed appropriate. The daily recordings include a document known as “How has your day been”. Service users are supported to indicate how they have felt and details of activities that they have participated on a daily basis. The format is in pictorial format. All records in regards to the service users are kept secure and confidential in a locked office. Through interviewing the registered manager the inspector is satisfied that the manager handles the service users information in a confidential manner in line with the confidentiality policy. No 11 Pathways G56 G06 S65292 No 11 Pathways V248549 070905 Stage 41.doc Version 1.40 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 standard(s) 12,13,14,15&17 It is the inspector’s view that service users are supported to undertake various activities both in the home and in the community in line with their ability and interests. EVIDENCE: Staff take responsibility to arrange and facilitate activities in the home. The inspector was satisfied through observations made during the inspection and from records seen that staff encourage service users to be involved with many activities and organisations outside the home dependant on their ability. From the records seen during the inspection it was noted the service users attend day services, as well as take part in activities such as swimming and horse riding. One-service users who care was tracked during the inspection attends day service three times weekly, attends three swimming sessions and a trampoline session once weekly. No 11 Pathways G56 G06 S65292 No 11 Pathways V248549 070905 Stage 41.doc Version 1.40 Page 12 The home now has a multi-sensory room, which had art and crafts materials available as well as equipment to provide massage equipment and other relaxation techniques such as aromatherapy. The inspector was satisfied that the service users are encouraged by staff and management to participate in the local community. The individual service plan seen by the inspector showed evidence of the service user going out to various local places. During the inspection service users were taken out by staff. The inspector was informed that one-service users was being taken out for lunch. Staff provide the service users with the assistance with their finances. Receipts of expenditure were seen on service users files. Details of family and friends were evidenced on the individual service user files. Family and friends are always welcome in the care home. Evidence was seen on service users files of family involvement. There are three meals offered daily when service users are present in the home, with additional drinks and snacks. Staff present appeared flexible to meet service user needs and fit in with day care arrangements and activities. The home was found to have ample food supplies. The inspector saw the food storage facilities; dry stocks were appropriately stored. The freezer was seen which urgently need to be defrosted. Fresh meat that had been frozen was not dated. Evidence was seen that frozen foods were not appropriately wrapped. It was also noted that foods in the fridge was not dated as to when opened. No 11 Pathways G56 G06 S65292 No 11 Pathways V248549 070905 Stage 41.doc Version 1.40 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 standard(s) 18 &20 It was the inspectors view was that medication was being accurately administered on a daily basis however staff must evidence this by accurate recording. EVIDENCE: The inspector was satisfied through indirect observation that the staff are very flexible with regards to meal times, bedtimes and activities. The daily routine is managed around the service users on a daily basis. On inspection of the service user plans it was evident that staff take into account individual needs. This was partially evident on one service users file where staff have to be observant of the service users mood before undertaking certain activities. The inspector saw during the inspection an agency staff member assist a service user from the bathroom in appropriately dressed. This was immediately raised with the registered manager who spoke with the staff member in question. This sought of incident must not be repeated. All staff working in the home must treat all service users with dignity and respect at all times. No 11 Pathways G56 G06 S65292 No 11 Pathways V248549 070905 Stage 41.doc Version 1.40 Page 14 The medication storage was in good order. Medication is provided by the chemist in doset boxes one was incorrect. Records indicated that there should be a total of six tablets each morning however there were eight present in the doset box. The registered manager checked records, which indicated that staff had recorded that they had received in to the home a total of six for each day. Further investigation found that the chemist had administered a smaller dosage and thus there were two extra tablets. However it highlighted that staff had not properly checked or accurately recorded the incoming medication into the home. Spot checks that were made on additional medications stored which were all correct however it was noted that eye drops, for one service user not been dated as to when opened and were inappropriately stored. MAR sheets were found to be in order with signatures. No 11 Pathways G56 G06 S65292 No 11 Pathways V248549 070905 Stage 41.doc Version 1.40 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 standard(s) 22&23 The inspector believes that the registered manager actively responses to complaints and endeavours to achieve satisfactory outcomes for the complainants. EVIDENCE: Adult protection policies and procedures are in place. The registered manager was aware of procedures and was very clear about her responsibilities to follow procedures. The complaints procedure seen at the time of inspection for service users was clear and the information was available in pictorial format. There have been seven complaints since the previous inspection all of which had been acted upon appropriately, investigation completed if appropriate and the outcomes were recorded. At the time of inspection there was one complaint being investigated. The inspector noted that a service user had made one of the complaints. The complaint was addressed appropriately with a satisfactory outcome. This is reassuring the service users are able to made complaints when appropriate. Current staff have Criminal Bureau checks in place. There are financial policies and procedures in place to protect service users finances. Service users file contained evidence of receipts of monies spent. No 11 Pathways G56 G06 S65292 No 11 Pathways V248549 070905 Stage 41.doc Version 1.40 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 standard(s) 24,25,26,27,28,29&30. It is the inspectors view that there are issues regarding the standard of the environment that need to be addressed to ensure a suitable environment for all service users. EVIDENCE: The inspector was satisfied that the premises are suitable for the stated purpose, and it is accessible to service users. The service users’ bedrooms are of adequate size. There is sufficient light, heat and ventilation. The service users have access to the entire home with the exception of the individual rooms of others. All the communal areas are accessible including the courtyard area. There is a dining area situated next to the kitchen. An area of the dinning room has now been partition off to provide the multi-sensory room. The home has sufficient numbers of toilet and bathroom facilities conveniently located on each floor. During a tour of the premises it was noted that many areas required plaster to be replaced and cracks to be filled in particular around doorframes. No 11 Pathways G56 G06 S65292 No 11 Pathways V248549 070905 Stage 41.doc Version 1.40 Page 17 There are many window coverings broken or not in place. All windows should have suitable coverings to ensure that the privacy and dignity of service users is preserved. The main communal lounge furniture has been replaced although the inspector noted that the old settees were still in use in the multi-sensory room. These were noted as in a state of disrepair and require replacing. The registered manager stated that the plan was to purchase beanbags. Bedroom 5 had a severely stained carpet, which should be cleaned, and if needed replaced. There is domestic support provided monthly however this is a large home that cares for service users with unpredictable behaviour. Throughout the home there was a need for areas such as walls, carpets and woodwork that needed attention. On balance however the inspector recognises that the registered manager actively works towards ensuring that the environment is adapted to meet service users needs. A new service user is currently being assessed, a Mediterranean toilet has been built in to meet the individuals needs this is deemed good practise. There are two laundry facilities one of domestic size that is situated in a small room in the main office area for service users to use and one newly installed industrial machine with sluice facility in a second area of the office. The situation of these machines is not ideal, at the time of inspection it was cluttered and there is clearly a lack of space. It remains a recommendation that the registered manager monitor the usage with the current service users, as the home gains full occupancy there may be a need to reconsider the position of these machines. On inspection of the dryer it was noted that it urgently required the lint to be removed, which could potentially become a fire hazard. The homes development plan was seen and provides a maintenance and redecoration plan although the inspector noted that some of the planned work had not been achieved within the timescale set. No 11 Pathways G56 G06 S65292 No 11 Pathways V248549 070905 Stage 41.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34 &36 The inspector believes that there was at this time adequate staffing however all staff must be fully ware of service users needs to ensure that service users are appropriately cared for at all times. EVIDENCE: The inspector was informed that there are three support staff on duty for five service users throughout the day with one waking night and one sleep in. The registered manager stated that there would be an slight increase in staffing by one additional staff on a 10.00-7.00 shift once the service users in placement goes up to six. There is an on call emergency procedure in place. There has been a vacancy for the deputy managers post for some months, and there are several vacancies on the staff team that are currently being filled by Bank or Agency staff. The inspector raised concern, as this is an establishment that particularly benefits from a stable staff team. A recent incident, which was in the process of being investigated, highlighted that not all staff were aware of service users individual needs. A staff member had bathed a service user and was unaware the service user liked to soak in the bath, such information is clearly recorded in the service users care plan. The staff member has stated that she was unaware this. No 11 Pathways G56 G06 S65292 No 11 Pathways V248549 070905 Stage 41.doc Version 1.40 Page 19 The registered manager stated that a deputy manager and administrator had been appointed and were currently under going relevant checks prior to employment. Two of the current service users require one to one support at times. Service users can display challenging behaviour, which was seen during the inspection, this requires staff to be immediately available to deal with situations as they arise. The inspector saw information regarding the prospective service user to be placed in the near future, given this service users needs there may be an impact on the current staffing, provided. The registered manager may have to further revise staffing to ensure that all of the service users needs can be met. This will be inspected more thoroughly at the next inspection. The registered manager holds files for staff in line with regulation. The files contained with copies of passports, identification and health checks, references and confirmation of Criminal Bureau checks being completed. Staff meetings are held regularly, minutes were seen which confirmed that in addition to day-to-day issues staff discussed issues such as: Service users Policies and procedures Inspection Organisational issues Minutes evidenced that staff have the opportunity to raise issues of importance to them in this forum. Service users are supported by key staff, which enables a good relationship to develop. Supervision records were seen with regard to three members of staff including a regular agency staff member. Evidence was seen to show that supervision in excess of the National Minimum Standards of at least six times yearly. Staff had also completed appraisals, which were seen at the time of inspection. No 11 Pathways G56 G06 S65292 No 11 Pathways V248549 070905 Stage 41.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,39,41&42 The inspector believes that the home is run by a registered manager is competent to run the care home in line with its stated purpose. EVIDENCE: The registered manager has the Registered Manager’s award. She has in excess of twelve years experience of working in a residential care setting and was able to demonstrate a good understanding of service users needs and the home’s aims and objectives. The inspector continues to be satisfied that the registered manager is competent and experienced to run the care home in line with its stated purpose. Records were seen during the inspection in relation to Schedule 4 of the Care Standards Act. Recordings were generally of good standard and contained relevant information. However some of the daily entries were not legible. As previously stated care plans and risk assessments are not up to date. No 11 Pathways G56 G06 S65292 No 11 Pathways V248549 070905 Stage 41.doc Version 1.40 Page 21 Monthly-unannounced visits are being made and reports up to July 05 were available for inspection. The inspector was informed that the August visit had taken place but the report was to follow. The inspector noted that relevant issues were being highlighted within the reports to provide guidance and direction for the registered manager. Up to date health and safety certificates were in place. However it was noted that there was only two fire drills recorded, one for March 05 and one in September 05. The registered manager stated that one should have been completed in June however there was no evidence to support this information. This remains an outstanding requirement. No 11 Pathways G56 G06 S65292 No 11 Pathways V248549 070905 Stage 41.doc Version 1.40 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 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 1 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 2 3 3 3 2 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 x 2 Standard No 31 32 33 34 35 36 Score x x 2 3 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 No 11 Pathways Score 1 x 2 x Standard No 37 38 39 40 41 42 43 Score 3 x 3 x 2 2 x G56 G06 S65292 No 11 Pathways V248549 070905 Stage 41.doc Version 1.40 Page 23 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 YA6 Regulation 15.1 Requirement The registered manager must ensure that care plans are completed and clearly identify all of service users needs. The registered manger must ensure that all unnecessary risks to the healthy and safety of service users are identified are so far as eliminated. The registered manager must ensure that all foods are appropriately stored and dated . The registered manager must ensure that all staff treat service users in a dignified and respectful manner at all times. The registered manager must ensure all medication is recorded and administered safely and accurately.(Timescale 15/4/05 not met) The registered manager must ensure that all of the damaged areas of the home be repaired and decorated. The registered manager must ensure that suitable furniture and furnishings are provided suitable to meet the needs of service users. The carpet in SR room must be Timescale for action 31/10/05 2. YA9 13.4 31/10/05 3. 4. YA17 YA18 16.2(I) 12.1 30/9/05 30/9/05 5. YA20 13.2 30/9/05 6. YA24 23.2 24/12/05 7. YA24YA26 16.1( c) 24/12/05 8. YA26 16.2 ( c) 31/10/05 Page 24 No 11 Pathways G56 G06 S65292 No 11 Pathways V248549 070905 Stage 41.doc Version 1.40 9. 10. YA30 YA30 23.2 23.4 11. YA33 18.1 12. 13. YA41 YA42 17 23.4(e) cleaned thoroughly to remove stains or replaced. The registered manager must ensure that all areas of the home be kept clean The registered manager must ensure that dyers are cleaned regularly and maintained free from lint. The registered manager must ensure that all staff working in the care home are fully aware of service users needs The registered manager must ensure that all recordings made by staff are legible. The registered manager must ensure that fire drills are completed at least three monthly.(Timescale of 31/3/05 not met) 30/9/05 30/9/05 30/9/05 30/9/05 31/12/05 14. 15. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA30 Good Practice Recommendations It is recommended that the registered manager monitor the usage with the current service users, as the home gains full occupancy there may be a need to reconsider the position of these machines. No 11 Pathways G56 G06 S65292 No 11 Pathways V248549 070905 Stage 41.doc Version 1.40 Page 25 Commission for Social Care Inspection Gredley House 1-11 Broadway London E15 4BQ 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 No 11 Pathways G56 G06 S65292 No 11 Pathways V248549 070905 Stage 41.doc Version 1.40 Page 26 - 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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