Inspection on 23/05/07 for St Albans Place (14)

This inspection was carried out on 23rd May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Albans Place (14) 18/01/06

St Albans Place (14) 23/08/05

St Albans Place (14) 24/02/05

St Albans Place (14) 14/09/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Blenheim House

Prince Bishop Court

Park View (15)

Craigmore House

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

CARE HOME ADULTS 18-65 St Albans Place (14) Windy Nook Gateshead Tyne & Wear NE10 9SP Lead Inspector Mrs Eileen Hulse Key Unannounced Inspection 23 May 2007 09:00 St Albans Place (14) DS0000007406.V334696.R02.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 St Albans Place (14) DS0000007406.V334696.R02.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. St Albans Place (14) DS0000007406.V334696.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Albans Place (14) Address Windy Nook Gateshead Tyne & Wear NE10 9SP 0191 469 7882 0191 438 0159 st@albansst.wanadoo.co.uk 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) Northumberland, Tyne & Wear NHS Trust Mrs Carol Ann Ruddick Care Home 4 Category(ies) of Learning disability (4), Learning disability over registration, with number 65 years of age (4), Physical disability over 65 of places years of age (1), Sensory Impairment over 65 years of age (1) St Albans Place (14) DS0000007406.V334696.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 18th January 2006 Brief Description of the Service: St Albans Place is a detached bungalow located within the Windy Nook area of Gateshead. It is close to a variety of local amenities and bus routes. The home has an enclosed rear garden and patio area with level access from the utility and lounge areas. There is also a small garden to the front of the house, which has ramped access. The bathroom and two of the bedrooms are provided with overhead tracking. There is an adapted bath, which is suitable for a person who has a physical disability. The design, layout and facilities of the home enable it to be suitable for people who have a physical disability. A loop system is installed to assist people who wear hearing aids. The home also has an adapted vehicle, which is appropriate for people who use a wheelchair. The home is registered to provide personal care for four adults over the age of 65 with a learning disability. The home is not registered to provide nursing care. It is managed and staffed by Northumberland, Tyne and Wear NHS Trust formally Northgate and Prudhoe NHS Trust. The philosophy of the home is to support and enable service users to take part in a range of activities in the community and to take part in domestic routines within the home. The weekly fees are £1175:63 to £1175:63 per week depending upon care needs. Additional charges are made for personal items such as toiletries, hairdressing, newspapers, and theatre tickets. St Albans Place (14) DS0000007406.V334696.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that took 6hrs 45mins to complete over a one day visit to the home and was carried out as part of the annual inspection programme. The Registered Manager was not present for the visit but the Deputy Manager who is currently Acting as Manager for six weeks was present throughout the day and some time was spent with her looking at the progress of the service. Time was also spent talking with service users, some service users have communication difficulties and therefore were not able to verbally express how they feel about the service. Members of staff on duty throughout the visit were able to discuss their views about the home, there were no visitors to the home on that day, however, five completed questionnaires were received from relatives and healthcare professionals. How care staff help and support service users was observed throughout the visit and a lunchtime meal was taken with the service users and the staff on duty. Information about the quality of life and care received by service users was collected using a system called ‘case tracking’. This involves following the care and experience of a group of service users by looking at care plans, talking with people, sampling records such as assessment records, complaint records, medication taken by service users and the records. The judgements made are based on the evidence made available during the visit to the home and from the pre inspection questionnaire and completed questionnaires obtained from the home before the visit was made. This gave up to date information about the home to include within the report. What the service does well: This is a well run home with good staff support and commitment. St Albans gives the service users a good fulfilling way of life, the quality of care provided to the people living there is excellent and the staff are caring and support service users to make decisions that affect their everyday lives and to support them in running their home and ensuring they have a fulfilled and varied social life. Young staff have brought new ideas into the home and they have become very much part of the home. There is a good rapport between service users and staff and the staff team really strive to occupy service users and to give them a good social life out and about. The healthcare needs of people are well met with other healthcare professionals fully involved, service users need more support as their health needs are changing. All furniture within the home that is purchased is planned around the future needs of the service users. The care plans contain good information and tell staff how they can meet all of the needs of the people living in the home. St Albans Place (14) DS0000007406.V334696.R02.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. St Albans Place (14) DS0000007406.V334696.R02.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 St Albans Place (14) DS0000007406.V334696.R02.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good assessments are included within the plans of care for all service users that help to form the basis of the individual care plan, this ensures that before admission, the home is able to know if the care needs can be met by them. EVIDENCE: All service users living in the house have had needs assessments carried out by a Care Manager and the Manager of the home prior to their admission. When a vacancy occurs, a care manager makes a referral to the home and the prospective service user makes several visits to either to share a meal with the people who live in the house or to spend some time in the home with them. Following the visits, the service users are asked if they would like the person to live with them on a permanent basis. Prior to admission and the homes assessment of need, the occupational therapist also carries out an assessment to ensure the correct equipment is installed prior to moving in. This process checks that the information given is accurate and that the care needs of the person can be met by the home. This information is also used within the review process. St Albans Place (14) DS0000007406.V334696.R02.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 and 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The care plans contain all aspects of person centred care, they are up to date, well maintained and include comprehensive, detailed information about service users as individuals and this helps staff to provide good quality care. The risk assessments form part of the care plans. They are well maintained, and ensure that service users can take risks as part of their everyday lifestyles. EVIDENCE: The care plans have recently been reorganised and information is now stored in a dedicated file used for the care plan only. It contains the profile of the service user, individual needs care plan, the Care Managers care plan and the homes initial assessment and where necessary the occupational therapist assessment. St Albans Place (14) DS0000007406.V334696.R02.S.doc Version 5.2 Page 10 The care plans describe in great detail the wishes/aspirations of the service users, their strengths and likes/dislikes. They are easy to follow and ensure that the special needs of the service users are recorded and follow a complete program of care giving good guidance for the staff to follow ensuring that the care needs are continuously identified and met. An overview review/summary is carried out every month and covers up to date activities/social life/health/health aspects and training and courses and this record ensures the care plans are always up to date and acts as a checklist. Every month the key workers and manager or deputy manager assess the information and sign the sheet for the support plan to see if any needs have changed. The care plans are very detailed and well recorded and give good guidance to staff, they explain the routines of the day and care plan entries included such as (name) ‘I like my music playing softly until I go to sleep’ and ‘I wish to say my prayers every night this is very important to me’. Information is clearly given to guide staff such as ‘make sure you have your rosary around your hand and staff will say prayers out loud’. Another stated (name) does not attend church now but likes songs of praise and has a book to sing along to the programme. The care plans also detail decisions service users have made and explain how staff can give support in ensuring service users wishes are carried out and the needs met. The risk assessment records have been implemented by the Trust and all staff sign to say they have read and understood them. They are completed and well maintained and cover what the risk is, what risks are associated with it, the benefits of taking the risk, how the service user has communicated their wish to take part, who may be harmed and how the benefits can be maximised. They give step by step information so that they can be followed by staff in various situations. St Albans Place (14) DS0000007406.V334696.R02.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): 12, 13, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. There is a good range of social activities made available to all service users to fulfil lifestyles and this makes sure they are able to make positive choices on how they choose to spend their leisure time. Service users are supported to maintain personal relationships and friendships and to maintain contact with their families. This recognises the rights of service users. Service users are offered varied and nutritious meals with good choices for everyone. EVIDENCE: All daily routines of the home are centred on the preferences of the service users. During the visit, one service user was visiting the bank then after lunch they both went to Sunderland Empire to see a show. St Albans Place (14) DS0000007406.V334696.R02.S.doc Version 5.2 Page 12 Information is recorded in the care plans identifying courses service users have attended and currently one service user attends castlegate college and has just completed woodwork at the Edward Lloyd trust and (name) was keen to show the work he had completed at the centre, he also goes to Newburn Leisure every week accompanied with an enabler for indoor cycling An enabling service ensures that all service users living in St Albans have an individual activities programme to carry out activities on a one to one basis with an activity of the service user’s choice, other activities that take place have been chosen by service users to be carried out by all the service users joining in as a group. Staff access information from the Internet, the local library and use information leaflets to help service users choose what they want to do. Newspapers advertising rail tickets are often purchased following suggestions from the staff and the enabling service. Monthly service user meetings are held to discuss what activities they want to be involved with and where they would like to go and any issues they want addressed, notes are taken and minuted in a book that is dated and signed. Quite often service users visit the following theatres, Theatre royal, Sunderland Empire and the Customs House as they frequently and automatically send out flyers and general information about future productions, staff then assist and support service users to choose if they want to go. Community links include the church hall light bite which is a coffee morning, music therapy at Allerdene Community Centre, theatres, food shopping which service users enjoy helping with and shopping at the metro centre. Service users have good contact with friends and families. Two service users families live down south and keep in touch by telephone and send letters and cards. Another service user goes out regularly with family. The home also has a volunteer twice a month and a retired member of staff also keeps in touch and visits. The family of a recently deceased service user also continues to visit the home and maintain contact. During the visit, a lunchtime meal was taken with service users who were at home for the day. The meal consisted of sandwiches and crisps, the menu showed that the evening meal consists of something cooked when everyone is home. There was good rapport between the service users and staff during the meal and help and assistance was discreetly offered to service users if they needed it. St Albans Place (14) DS0000007406.V334696.R02.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 excellent. This judgement has been made using available evidence including a visit to this service. The staff team have been trained in the use of the specialist equipment used within the home and this keeps service users safe. A number of specialist professionals are currently accessed and used by the service that includes, physiotherapist, an occupational therapist and a podiatrist. This ensures the healthcare needs of service users are identified and met Good procedures are in place on the administration of medicines that helps to make sure service users are given their medication safely. EVIDENCE: Through observation and reading through care plans it was evident that good care practices take place in this home. Staff work sensitively with the service users, showing discretion when assisting with personal needs, and demonstrating respect and sensitivity when interacting generally. St Albans Place (14) DS0000007406.V334696.R02.S.doc Version 5.2 Page 14 Through the person centred care plans, the dignity, comfort and personal care of service users, include clear guidelines for staff to follow in relation to equipment that is used to meet the needs of service users. The home has a policy and procedure on the administration of medicines used in the home. A monitored dosage system is used and the policy in place covers areas on the recording, administration, safekeeping and disposal of medications held within the home. All medications are recorded on individual medicine administration record sheets that are up to date and well maintained. At all times, medicines are given to service users in the presence of two staff and all staff in the home has completed the accredited medication training ‘Safer Handling of Medication’. Nobody holds their own medication although one service user does remind staff of his medication when due. Staff return all un-used or un-wanted drugs personally to the pharmacy and use a delivery and returned recording book that is signed by the pharmacist accepting the drugs and the member of staff handing them over. All medications are recorded in individual books for service users that are used as a cross-reference medication check on receipt of medications from the pharmacy. Medications are also recorded within the medication delivery file on individual sheets. Every night two staff will do a drugs check to ensure the medicines in the home correspond with the records. St Albans Place (14) DS0000007406.V334696.R02.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 excellent. This judgement has been made using available evidence including a visit to this service. The home has a clear and easy to understand complaints policy and procedure which is accessible to service users and their relatives should they have a concern or complaint about the service. The home has good adult protection procedures that will help to protect service users should an abuse situation arise or be suspected. EVIDENCE: The complaints policy is written in a format that is suitable for the people in the home to understand. Staff confirmed they are aware of how to deal with a complaint should one be made whilst they are on duty. Any complaint or concern received by the service is recorded and acted upon and records showed that the last complaint made was the only complaint made in the last twelve months and the head office of the Trust dealt it with. The complaint was in connection with the parking of the homes mini bus and therefore the health and safety department had to carry out a risk assessment. Protection of Vulnerable Adults (POVA) procedures are available in the Home for staff guidance and includes whistle blowing. The Local Authority procedures produced by Gateshead Council are also available in the Home for staff guidance. Staff records confirmed all staff have received training on the protection of vulnerable adults. St Albans Place (14) DS0000007406.V334696.R02.S.doc Version 5.2 Page 16 Staff were able to describe and give a good account of appropriate actions to be taken on suspicion of, or witnessing abuse. St Albans Place (14) DS0000007406.V334696.R02.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The house is homely and comfortable, however, the hall carpet should be replaced as part of the home’s refurbishment plan. The home is clean and there are no odours within the home. This provides service users with a nice home within a safe environment. EVIDENCE: The bedrooms were found to be homely and personalised to suit individual tastes and have a homely, comfortable feel and service users demonstrated a real sense of ownership in their own space in the home. The bedrooms are all decorated to their own taste and the service users chose the decoration and furniture. However, the hall carpet is worn and it is rucked in several places and could cause a tripping hazard for other service users and staff. There are good cleaning and maintenance schedules for both internal and external areas of the house. The gardener was present maintaining the wellSt Albans Place (14) DS0000007406.V334696.R02.S.doc Version 5.2 Page 18 kept gardens that have accessibility for all service users who live in the home via the lounge patio door or through the utility room. All staff currently employed have completed infection control training as part of their annual mandatory training and there is an up to date manual relating to infection control for all staff to refer to. St Albans Place (14) DS0000007406.V334696.R02.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff that are well trained and have a good understanding of their roles and responsibilities that helps to support service users and the home have a good recruitment policy that is used when employing new staff. People can be expected to be cared for by staff that have the skills and knowledge to support them. EVIDENCE: The home has a policy and procedure on staff recruitment that is used when recruiting prospective staff. The Deputy Manager was able to explain in detail the process that is used. Following the interview, the prospective member of staff will meet with the service users to gain their views. The home has a very low turnover of staff, only one member of staff has left in last twelve months. Usually, staff leaving the service is due to retirement. Staff records could not be examined as the records are held centrally at the trust Head Quarters. St Albans Place (14) DS0000007406.V334696.R02.S.doc Version 5.2 Page 20 Discussions held with the acting Manager and members of staff and observations made during the inspection, evidenced that staff have a good understanding of their roles and responsibilities. Staff stated that they are provided with training specific to the needs of the service users and this has allowed the home to have a mix of skills and experience among the staff group necessary for the tasks they are expected to undertake. No staff members working in the home at this time are under the age of 18 years. The staff team all receive regular training and the staff training records showed that all staff have received training that included LDAF Framework in Learning disabilities, Protection of vulnerable adults, Financial induction and all annual mandatory training. Certain staff have received specialist training to include Medazolan training regarding rectal administration of medication. St Albans Place (14) DS0000007406.V334696.R02.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The Manager is well experienced to run the home and shows good leadership, guidance and support to the service users and staff team. This ensures the home meets it’s stated purpose and is a pleasant place for service users to live in. There were no health and safety issues that would compromise the safety of service users and staff working in the home. EVIDENCE: The Manager has been in post for almost three years and prior to working in this home has been employed as a Manager in other homes for the last nine years and has vast experience working with this service user group. She is a St Albans Place (14) DS0000007406.V334696.R02.S.doc Version 5.2 Page 22 qualified first level nurse and has gained her RNLD and was a ward sister prior to managing in community care homes. The Manager shows strong leadership skills in managing a staff team and she has completed the A1A2 Assessor award and completed the Registered Managers Award. Clear lines of accountability were found to be in place and good contact with external management is evident. All staff receives mandatory training in health & safety matters including Food Hygiene, Moving & Assisting, Fire Safety and First Aid. New members of staff also receive this training within their Induction/Foundation programmes, which also includes Infection Control training. St Albans Place (14) DS0000007406.V334696.R02.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 X 4 X 5 x 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 4 14 X 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 4 x 4 X 3 X X 4 x St Albans Place (14) DS0000007406.V334696.R02.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA24 Regulation 23 Requirement The hall carpet should be replaced as part of the homes refurbishment programme. (Previous timescale of 01 April 2006 not met) Timescale for action 01/09/07 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 St Albans Place (14) DS0000007406.V334696.R02.S.doc Version 5.2 Page 25 Commission for Social Care Inspection South Shields Area Office 4th Floor St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 St Albans Place (14) DS0000007406.V334696.R02.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!