Inspection on 28/04/08 for Richford Gate, 52

This inspection was carried out on 28th April 2008.

CSCI found this care home to be providing an Good service.

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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Richford Gate, 52 23/07/07

Richford Gate, 52 09/05/06

Richford Gate, 52 03/11/05

Richford Gate, 52 01/04/05

Richford Gate, 52 20/01/05

Richford Gate, 52 07/07/04

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 Richford Gate, 52 52 Richford Gate Richford Street Hammersmith London W6 7HZ Lead Inspector Sheila Lycholit Key Unannounced Inspection 28th April 2008 10:05 28/04/08 Richford Gate, 52 DS0000019146.V362132.R01.S.doc Version 5.2 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 Richford Gate, 52 DS0000019146.V362132.R01.S.doc Version 5.2 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. Richford Gate, 52 DS0000019146.V362132.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Richford Gate, 52 Address 52 Richford Gate Richford Street Hammersmith London W6 7HZ 020 8749 0307 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) info@yarrowhousing.org.uk Yarrow Housing Ms Judy Miller Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Richford Gate, 52 DS0000019146.V362132.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 8 23rd July 2007 Date of last inspection Brief Description of the Service: 52-53 Richford Gate is a registered care home providing support and accommodation for eight men and women with a learning disability. The service is provided by Yarrow Housing, a ‘not for profit’ organisation, in a building owned by Kensington Housing Trust. The home, which is comprised of two separate flats, is well located, close to facilities in the local community and the shops and transport links of Shepherds Bush and Hammersmith. The home provides accommodation on two floors and is not accessible to people with mobility difficulties. Each service user has a single room. The accommodation does not have its own garden. Richford Gate, 52 DS0000019146.V362132.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means that the people who use this service experience good quality outcomes. The unannounced visit took place on Monday 28th April 2008 from 10.05am until 3.50pm. The Manager who had been doing the sleep-in duty made herself available throughout the visit. The Manager was on duty with 2 support staff and the domestic assistant. One of the Deputy Managers and another support worker came on duty at 2pm for the afternoon/evening shift. There are currently 7 tenants at Richford Gate and the service has 1 vacant place. Five tenants were at home during part of the inspection visit but were also attending a range of activities, including college, community projects and The Gate day service. One tenant had been staying at his parents for the weekend and was expected back that evening. Questionnaires were returned by all tenants and the Inspector spoke with 3 people during the visit and met with 2 others. The Manager had completed an Annual Quality Assurance Assessment (AQAA). Feedback questionnaires were received from 5 staff. The Manager showed the Inspector around the building and 2 tenants showed her their rooms. Fees and charges vary and are negotiated individually with the local authority. What the service does well: What has improved since the last inspection? Two new tenants have moved to Richford Gate since the last inspection. The admission process had improved since the previous tenant moved in with little opportunity for an assessment or preparation. Both new tenants had visited Richford Gate, 52 DS0000019146.V362132.R01.S.doc Version 5.2 Page 6 the service, including having overnight stays and staff had been able to undertake their own assessment, as well as receiving information from the learning disability team. Menus show that steps are being taken to encourage healthy eating and takeaways are purchased only once a week. Visits on behalf of the provider, Yarrow Housing, are taking place regularly and a report is available in the home. 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. The summary of this inspection report can be made available in other formats on request. Richford Gate, 52 DS0000019146.V362132.R01.S.doc Version 5.2 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 Richford Gate, 52 DS0000019146.V362132.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 and 5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Up to date information about the service is available, in an accessible format. A sound admission procedure is in place that fully involves the prospective tenant. EVIDENCE: Information about the service is provided in an accessible format and regularly updated. Records for the 2 most recently admitted tenants and 1 long term tenant were looked at. Each tenant’s file had a copy of the service user’s guide, tenancy agreement and contract, which included fees and charges. Records relating to the admission of two tenants showed that in addition to information provided by the Care Manager, staff had undertaken an assessment, which had involved the prospective tenant and his family. Each tenant had the opportunity to visit the service and to have overnight stays before making a decision to move in. The process of moving in is agreed with prospective tenants at a placement meeting held following completion of the assessment, when a transition plan is agreed. Richford Gate, 52 DS0000019146.V362132.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Tenants receive person centred care and support, which recognises their individual needs. Tenants are well supported to take part in decision making through key working, the use of accessible documents and multi-media and by regular residents’ meetings. EVIDENCE: The records of 3 tenants were looked at and were generally in good order. PCPs have been developed in a pictorial format and recent reviews have also been recorded using colour, illustrations and symbols to make them accessible. Notes of reviews are also kept using text. Staff were assisting one tenant to prepare for his forthcoming review using a range of media. Daily support guidelines had been developed for each tenant with their involvement. Files contained a copy of tenant’s preference regarding gender care. Richford Gate, 52 DS0000019146.V362132.R01.S.doc Version 5.2 Page 10 Monthly summaries were seen for 2 tenants, which show developments during the month, including significant events and any changes in the support/care plan and PCP. No monthly summaries had been completed for one tenant who had moved to the service in September 2007. A file audit by the Manager had identified this omission and also the absence of a completed risk assessment. Notes of the tenant’s review in February were available and showed that he was receiving a range of support. This was confirmed by the tenant himself who commented that he found staff made time for him, in particular his key worker. Records of residents’ meetings show that they take place weekly and are usually well attended. A range of issues are discussed, including menus for the coming week, outings and staff changes. Individual risk assessments cover a range of activities, including travelling independently and handling money. Risk assessments for two tenants were up to date, though the risk assessment for one of the most recently admitted tenants had not been fully completed. This had been noted in the member of staff’s supervision notes. Richford Gate, 52 DS0000019146.V362132.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Tenants are supported in a range of community activities, including work placements, adult education classes and using leisure facilities. Good relationships are maintained with families and friends, who are encouraged to contribute to the development of the service. Staff continue to promote healthy eating. EVIDENCE: Records show that all tenants take part in a range of activities, in line with their PCPs and activity plans. One tenant has a regular evening job and others have work experience placements. Good use is made of local specialist services and projects, as well as mainstream activities and services. Staff support tenants on individual and group activities in the UK and abroad. Richford Gate, 52 DS0000019146.V362132.R01.S.doc Version 5.2 Page 12 Personal and emotional development is supported through one to one sessions with key workers and by referring tenants for psychological support. One tenant attends a speaking-up group as part of the plan to help her express her thoughts and feelings appropriately. Tenants’ cultural identity is supported through their activity programmes, choice of meals and holidays. Good relationships have been established with families and friends who are encouraged to visit regularly. A number of tenants spend time with their families, staying overnight on a regular basis. Relatives are encouraged to give feedback via the home’s quality assurance process. Discussion with the Manager showed that action had been taken regarding issues raised. The 2 kitchens were looked at during the visit. Both were clean and tidy, with a supply of fresh fruit available. Staff monitor tenants’ weight monthly and encourage healthy eating, though the weight and diet of two tenants is causing concern. Referrals to a Dietician are made for advice and guidance. Menus are discussed at tenants’ weekly meetings. Takeaways have been restricted to once a week and a wider variety of dishes introduced. Tenants have individual weekly cooking sessions to prepare them for more independent living. Richford Gate, 52 DS0000019146.V362132.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Tenants are fully involved in determining how they wish to be supported with personal care. Generally tenants’ health care needs are given a high priority. EVIDENCE: Records show that tenants contribute to the development of daily support guidelines through discussion with their key worker. Support guidelines are written in the first person and state clearly and in detail how the tenant wishes to be assisted. Detailed health action plans were seen, which identified tenants’ health care needs and action to be taken. Staff accompany tenants to appointments and follow up referrals to health care professionals. No health action plan or assessment of his health care needs were available for one of the newest tenants. The Manager confirmed that steps had been taken to book a dental check-up for him but the wrong date had been recorded and another Richford Gate, 52 DS0000019146.V362132.R01.S.doc Version 5.2 Page 14 appointment needed to be arranged. No record of previous illnesses or vaccinations had been made. Staff receive training in the administration of medication from Yarrow’s internal trainer. The Manager has also updated her knowledge by attending external training provided by Boots, which she found useful. No tenants currently manage their own medication. Staff have taken back responsibility for one tenant’s medication following an assessment. Reports show that 2 medication incidents have taken place since the last inspection, including a tenant having access to an unlocked medicine cupboard, while staff administered medication elsewhere in the building. Staff have been reminded to lock the cupboard or the office door when giving out medication. The Manager confirmed that action had been taken as a result of the incidents. Richford Gate, 52 DS0000019146.V362132.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Steps are taken to protect tenants while supporting their right to take part in community activities. An accessible complaints procedure is available and feedback is encouraged from families and other stakeholders. EVIDENCE: Yarrow Housing has an accessible complaints procedure, which is set out in the service user’s guide. While no formal complaints have been received in the past 12 months, records show that tenants and their relatives feel able to raise issues about the service. All staff have attended training in safeguarding adults. The Manager has attended training in the Mental Capacity Act, which she intends to disseminate to staff. As some of the staff attended safeguarding training 2 or 3 years ago, it is recommended that the local safeguarding adults co-ordinator is asked to attend a team meeting or workshop to update staff about current procedures. Two safeguarding adults referrals have been made in the last 12 months. Strategy meetings were held and action has been taken to reduce the risk of a reoccurrence. The local authority and CSCI were informed of the incidents. Richford Gate, 52 DS0000019146.V362132.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. While staff have taken steps to improve the environment over the past two years, the décor is in urgent need of improvement and bathrooms and lavatories need to be refurbished. The decision to delay implementing improved ventilation must be reconsidered. Office and sleeping-in facilities are cramped and need to be upgraded. Cleanliness throughout the flats, including both kitchens, is of a good standard. EVIDENCE: The flats are in need of redecoration, as communal areas in particular have become rather shabby. The Manager confirmed that redecoration will take place in the coming year. The flats are well supplied with bathrooms and lavatories but these are in need of refurbishment. Consideration should be given to providing a further walk-in shower to promote tenants’ independence. Tenants’ rooms are of a good size and tenants spoken with confirmed that they had the furniture and equipment that they needed. One of the televisions was on in a sitting room, with poor reception. This had been raised in the service’s own survey of tenants and relatives views in 2007. Richford Gate, 52 DS0000019146.V362132.R01.S.doc Version 5.2 Page 17 One of the tenants commented that Sky was being installed, which was confirmed by staff. Ways of improving office and sleeping-in facilities for staff should be considered. The office is very cramped, with only space for one member of staff to work. The use of the vacant bedroom could be considered to temporarily improve working space for staff. Lighting in the office needs improvement. Bare light bulbs throughout the building detract from a homely appearance. Ways of increasing storage space should also be considered, so that items, such as the ironing board and stationery are not left in the hallway. A decision regarding improvements to ventilation was deferred because of low occupancy, leaving the 7 tenants and staff to face another summer when temperatures in parts of the building become unacceptably high. There continue to be delays in carrying out repairs and maintenance, though a system for monitoring and following up outstanding work is in place. Richford Gate, 52 DS0000019146.V362132.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Although a number of posts remain vacant, the staff team work well together and consistent staffing has been maintained. Staff are encouraged to complete accredited training to at least NVQ3 level and receive good support through regular supervision. Staff communication is given a high priority. EVIDENCE: The staff team continues to operate with a number of vacant posts – currently four. The Manager said that recent interviews in March had not resulted in any appointments for the service. The Manager has assessed that the team would benefit from the appointment of more male Caucasian staff to enable key workers’ background to be matched, where possible, to tenants. Consistent staffing has been largely maintained through the use of bank and regular agency staff. The experienced senior staff team are involved with tenants on a day to day basis and model good practice. Feedback from staff in their questionnaires and in discussion was positive about the support they receive. A high priority is given to communication by means of handovers, communication book and team meetings. Richford Gate, 52 DS0000019146.V362132.R01.S.doc Version 5.2 Page 19 Recruitment is undertaken by Yarrow’s HR team, who carryout all appointment checks, including CRBs. Staff files are held at Yarrow’s head office and were not inspected at this visit. When looked at on previous occasions, staff files have been in good order, with all checks carried out. Yarrow has a policy of involving tenants in recruitment and a number of tenants, following training, have been involved in interviewing. Yarrow uses a structured induction based on the Skills for Care common induction standards. In discussion, the most recently appointed member of staff confirmed that he had received a good induction to the service and had undertaken all mandatory training. Staff are encouraged to complete NVQ training. Both Deputy Managers have completed NVQ4 and one has achieved the RMA. Two bank staff are enrolled on NVQ2 and the two permanent support staff are enrolled on NVQ3. Supervision notes were seen for two staff. These were very clearly written up, showing that a range of issues are covered, with action and timescales agreed. Supervision is scheduled monthly, when staff discuss each of the tenants they are key working. Staff development and training issues are also discussed. Richford Gate, 52 DS0000019146.V362132.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 41, 42 and 43 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The experienced senior staff team provide leadership to the service. Record keeping is of a good standard. A range of steps are taken to formally ascertain tenants’ views about the service and the wider development of Yarrow Housing. Visits on behalf of the provider are now taking place regularly. EVIDENCE: The senior staff team is well established and has ensured a good standard of service in spite of a high number of staff vacancies. The Manager has not yet completed NVQ4/RMA. After interruptions to her study, she has a new Assessor and plans to achieve the award in 2008. A summary of feedback about the service from tenants and other stakeholders is displayed in the office. The Manager was able to confirm action taken as a Richford Gate, 52 DS0000019146.V362132.R01.S.doc Version 5.2 Page 21 result of issues raised. Feedback from all of Yarrow’s tenants, which is available on line, contributes to the wider development of the service. Tenants are encouraged to attend a regular forum held by Yarrow Housing, where they can raise any concerns and hear about developments and changes. The finance sheets were seen for 2 tenants, which showed that all transactions are recorded and a running balance kept. A recent incident where some money was missing but later found has led to additional checks being made. One tenant is receiving specific support with handling money as part of his preparation for independent living. Recording by staff is of a good standard, in spite of the cramped office space. Yarrow’s policies and procedures are regularly updated. In their feedback two staff commented on what they perceived as a lack of consultation regarding a new policy on managing aggression and on pay when supporting tenants on holiday. The Manager was aware of staff concerns, which had been discussed with senior managers. Training records confirm that staff attend training in health and safety including refresher training every 3 years. Health and safety records show that a range of regular checks are undertaken. The fire risk assessment was reviewed in January this year. The fire detection system and fire fighting equipment are checked quarterly. The last 2 reports from the contractor recommended that the control panel be replaced. The Manager said that a request had been forward to Yarrow’s head office. The temperature of the hot water is regularly checked but no test of the water quality or steps to control Legionella have been taken for a number of years. The Manager has made a number of requests to the Housing Association for these checks to be made. Records show that visits on behalf of the provider now take place monthly, with a full report of the visit available in the home. Richford Gate, 52 DS0000019146.V362132.R01.S.doc Version 5.2 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 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 2 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 3 3 3 2 3 Richford Gate, 52 DS0000019146.V362132.R01.S.doc Version 5.2 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 2 3 Standard YA6 YA19 YA24 Regulation 15 12 23 Requirement Care/support plans must be reviewed at least monthly. All service users healthcare needs must be assessed. A decision to improve ventilation must be implemented and the planned redecoration take place as soon as possible. Bathrooms and lavatories need to be upgraded to provide facilities that promote tenants’ independence. Risk assessments must be updated promptly following an incident or accident. The fire alarm panel must be replaced in line with the maintenance engineer’s recommendations at his two recent visits. Steps must be taken to regularly check the water system to control the risk of Legionella. Timescale for action 31/05/08 31/05/08 31/05/08 4 YA27 23 31/07/08 5 6 YA42 13 23 31/05/08 31/05/08 YA42 7 YA42 13 31/07/08 Richford Gate, 52 DS0000019146.V362132.R01.S.doc Version 5.2 Page 24 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 YA23 Good Practice Recommendations Steps should be taken to ensure that staff have up to date knowledge of local safeguarding procedures by asking the Hammersmith and Fulham Safeguarding Officer to attend a team meeting or workshop. Office and sleep-in facilities should be improved. 2 YA28 Richford Gate, 52 DS0000019146.V362132.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Richford Gate, 52 DS0000019146.V362132.R01.S.doc Version 5.2 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!