Inspection on 16/01/06 for Station Road 159

This inspection was carried out on 16th January 2006.

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

The inspector 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Station Road 159 21/08/07

Station Road 159 26/01/07

Station Road 159 21/07/05

Station Road 159 01/12/04

Station Road 159 19/05/04

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 Station Road 159-159a Hendon London NW4 4NH Lead Inspector Margaret Flaws Unannounced Inspection 16th January 2006 09:00 Station Road 159-159a DS0000010532.V269969.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Station Road 159-159a DS0000010532.V269969.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Station Road 159-159a DS0000010532.V269969.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Station Road 159-159a Address Hendon London NW4 4NH 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) 020 8203 5029 020 8203 5029 159stationrd@norwood.org.uk Norwood Ravenswood T/A Norwood Mrs Victoria Kaye Connelly-Hall Care Home 14 Category(ies) of Learning disability (14), Learning disability over registration, with number 65 years of age (1), Mental disorder, excluding of places learning disability or dementia (14), Physical disability (1) Station Road 159-159a DS0000010532.V269969.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Limited to 14 adults with a learning disability (LD) and/or a mental disorder (MD). Specific service user over 65 years of age A specific service user who is currently resident in the home and is over 65 years of age can reside in this home. This condition will need to be reviewed when s/he vacates the home. Specific service user with Physical Disability A specific service user who is currently resident in the home with a physical disability (PD) can reside in this home. This condition will need to be reviwed when s/he vacates the home. 21st July 2005 3. Date of last inspection Brief Description of the Service: 159 and 159A Station Road are two self-contained buildings on one site that are currently registered as a single care home for fourteen adults who have a diagnosis of learning disability or mental disorder. One specified service user may also have a physical disability and another specified service user may also be over sixty-five years of age. The home is run by Norwood, a Jewish charity operating services for adults and children with learning disabilities. The two buildings opened in June 1997. 159 is a large detached property that has been adapted to accommodate five service users. The kitchen/diner, the lounge and managers office are situated on the ground floor. Four service user bedrooms and laundry are on the second floor and another bedroom on the third floor. 159A is a purpose built property located to the rear of the site. This building can accommodate up to nine people. There are currently eight service users accommodated. This allows one service user with specific identified needs to have additional personal space. There are six service user bedrooms on the first floor and three on the ground floor. There are toilet and bathroom facilities on both floors. There is a lounge, dining room, kitchen and laundry on the ground floor. Both houses have separate, enclosed garden facilities. The home has good access to local shops and the transport and other amenities of Hendon. The stated aim of the service is to provide high quality individualised residential care that will, together with day opportunity programmes enable people to maximise their educational and personal development. To develop a strong sense of religious and cultural identity, ensuring each person can self-determine their lifestyle and achieve their goals in life. Station Road 159-159a DS0000010532.V269969.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day. It was undertaken by Inspector Margaret Flaws, as part of the routine schedule of inspections for the home. There were no vacancies at either unit on the day of the inspection. The inspector was able to speak to eight service users (one of whom was nonverbal), the managers of each house and nine staff. No relatives visited during the inspection. A tour of the buildings and grounds, inspection of service user files, staff records, general home records and policies and procedures formed the basis of the inspection. Four new requirements were made and two restated from the last inspection. What the service does well: What has improved since the last inspection? All service users have clear contracts held on their files. Staff have received updated adult protection training. Two health and safety requirements have been met: stair carpet in the hall and on the stairs of 159a has been replaced with good quality vinyl, as has the carpet in a service user’s room in 159. Both managers have put in applications to CSCI for registration, and application to register the services separately is in progress. Station Road 159-159a DS0000010532.V269969.R01.S.doc Version 5.0 Page 6 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. Station Road 159-159a DS0000010532.V269969.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Station Road 159-159a DS0000010532.V269969.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2,3,5 Service users’ needs are fully assessed before they move in so that they can be confident that their needs will be met. EVIDENCE: There has been one new admission at 159a Station Road. The service user moved from living with family into the home and to date, is settling in very well. From examining the care plan and talking to staff, it was clear that this service users’ needs have been carefully assessed and repeatedly reviewed through the settling in period. One long-term service user who moved from 159a to 159 Station Road on request has settled in well there. The previous requirement for all service users to have a copy of terms and conditions on file has now been fully met. Station Road 159-159a DS0000010532.V269969.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7, 8 and 9 Service users’ personal, health and social care needs are assessed and regularly reviewed in consultation with them. Changes in care are well documented. Service users are fully involved in decision making in line with their abilities, and active in determining their own measure of independence. EVIDENCE: Five care plans were sampled at 159 and two at 159a. Most care plans contained detailed assessments, were comprehensively reviewed and updated regularly. Some care plans at 159 require reviewing. Service users spoken to gave good descriptions of how their care is assessed and reviewed. They are assigned key workers who work closely with them on meeting their needs and reviewing their care. Observation by the inspector and interviews with service users clearly indicated that service users are highly involved in decisionmaking about their lives on a small and larger scale. Staff were observed constantly asking, explaining and discussing daily routines and planning activities with service users. Daily routines are planned by the service users according to their preferences, with the support of staff. Service users spoken to were highly complimentary about the home, the quality of care and support and the ways that their independence was preserved. Station Road 159-159a DS0000010532.V269969.R01.S.doc Version 5.0 Page 10 Service users have comprehensive individual risk assessments kept on their files. These are regularly reviewed in consultation with service users. Risk stretching activities are an integral part of the home’s programme. Service user meetings are held at least monthly and also on an impromptu basis. Station Road 159-159a DS0000010532.V269969.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13,14, 15, 16 and 17 Service users live active lives according to their wishes and abilities, have ample opportunities for personal and social growth and leisure. They all have annual holidays and are supported to maintain links with family and community. Service users’ privacy and dignity is protected by staff. Service users are satisfied that their diet is culturally appropriate and healthy, and offers variety and choice. EVIDENCE: Some service users participate in educational and day centre activities. Like other activities, these are individually geared to each person’s needs as documented in their care plans. Service users are involved in a range of individual and group activities. The main activity at the home on the morning of the inspection was a singing session. Service users from both house participated. Station Road 159-159a DS0000010532.V269969.R01.S.doc Version 5.0 Page 12 Other activities that service users said they enjoyed included bowling, shopping for shabbat, day centre, individual beauty sessions, individual computer learning, fitness sessions and gardening. One service user said she has recently started a part-time job in Norwood’s head office. Many activities are individualised and there were sufficient staff rostered to insure one to one outings matched to service user’ wishes. The communal areas in both units were very welcoming and well supplied with DVDs, games, books and magazines for individuals to enjoy at their own leisure. Some service users have televisions in their own rooms. Service users at 159 actively described their late summer holiday to Spain, where they lived together in a villa, planned activities together, shopped and cooked, with the support of staff. One service user said that she didn’t go because she did not want to go on holiday. Another service user went to visit family in the USA, accompanied by a staff member. The manager of 159a said that all service users had been on holiday prior to the last inspection. The service is part of the Norwood and Jewish communities and there are links between service users in different Norwood homes. Jewish celebrations are an integral part of the life of the home. Most service users spoken to had some degree of regular family contact. Some went to stay with their families for the weekends or had visits from family. Service users fully participated in the running of the home, carrying out their assigned duties within the house, preparing for lunch and cleaning up. The inspector observed many respectful interactions between staff and service users. Lunch at 159 was observed during the inspection. It consisted of salmon, tuna or cheese sandwiches with two salads and fresh fruit. Rotational menus offer choice and were made from scratch using fresh ingredients. Both kitchens are kosher and Jewish meals are regularly offered. Service users’ preferences were sought and met. Fridges and food storage in both houses were inspected. There was plenty of fresh fruit and vegetables; foods opened were marked with the date of opening and temperatures recorded. Station Road 159-159a DS0000010532.V269969.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Personal care is provided in line with service users’ preferences. Health checks are routine. Medication policies and procedures are appropriate, reinforced by training and monitoring and adhered to by staff. EVIDENCE: Seven service user care plans were inspected. These set out the arrangements for providing personal care and staff interviewed could demonstrate a good knowledge of service users and their needs, and how they provided personal care to them. Service users have good access to regular health care appointments and specialist check ups, which is documented in the files. On the inspection day, one service user had a visit from an eye specialist to help with new glasses and another vision problem, which was rectified. The manager at 159 said that they have changed GPs because they were dissatisfied with quality of care. Medication records at 159 Station Road were inspected and were in order. There were no errors in the MAR sheets. Staff were observed giving medication in an accurate, safe and respectful fashion and preparing to give personal care appropriately. There were good guidelines on file for managing the care of those service users who are diabetic. Station Road 159-159a DS0000010532.V269969.R01.S.doc Version 5.0 Page 14 The medication policy and procedure contains a section on the administration of insulin and staff have received diabetes training. The procedure for administering insulin to a diabetic client at 159a has been written up by the manager but, along with a senior staff member, she described some frustration at still not being able to have this checked and signed by the service user’s diabetic nurse. The relevant GP has been enlisted to help rectify this problem, still an outstanding requirement. All staff have attended medication training and have regular refresher medication courses. The manager at 159a discussed the issue of an older service user refusing to have her regular mental health injections and how the service is managing this service user’s care. The Barnet PCT mental health team is fully involved and are contacting the home every two days to monitor and there has been significant input and support from psychiatrists and other mental heath professionals. While the service user has experienced a significant change of mood, there is currently no identified risk to herself or to others in the home. The manager said that this is a clear case of respecting the informed choice of the long term service user and providing support through the process. A major care conference is scheduled for February 2006. The service user’s care plan contained all the up to date information about the issue and risk assessments and behaviour management guidelines were clearly updated and monitored. Staff were observed working closely with the service users and providing appropriate support. Station Road 159-159a DS0000010532.V269969.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Service user concerns are considered and effectively addressed by formal and informal processes. Policies are in place to ensure that risk to service users from abuse is minimised. Staff have received updated adult protection training. EVIDENCE: One complaint has been received since the last inspection and this has been appropriately investigated and resolved. The home’s complaints policy and procedure is appropriate and accessible. The home’s Adult Protection Policy is comprehensive. A copy of Barnet Council’s Adult Protection Policy and Procedure has been obtained for staff to read. Staff have had recent adult protection training. Service user interests are also protected by Norwood’s lay advocate scheme. Station Road 159-159a DS0000010532.V269969.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 and 30 Service users live in a pleasant environment that is decorated and resourced to a high standard. Both houses were very clean and hygienic. Current failures in organisational maintenance support risk jeopardising the health and safety of service users and staff. EVIDENCE: Staff took the inspector on a tour of each building. Communal areas and bedrooms are comfortably furnished, very pleasantly decorated and well supplied with recreational and personal items. The home is of a high standard and is well resourced. The hall and stair carpet in 159 has been removed and replaced with vinyl flooring to meet a requirement from the last inspection. New flooring has also been put down in the 159 kitchen. Service users and staff said that they are very pleased with these improvements. Both houses were very clean, tidy and well presented. Infection control is maintained by safe working procedures, including a red bag system, and washing machines have sluice cycles. The carpet in one doubly incontinent service user’s room at 159a Station Road has also been replaced with vinyl flooring and the room no longer has an unacceptable odour, meeting another requirement. Station Road 159-159a DS0000010532.V269969.R01.S.doc Version 5.0 Page 17 Both managers identified significant organisational problems with the maintenance department. They said that, over the past few months, maintenance requests are not responded to within reasonable timeframes, lost in the system or only partially completed. Outstanding maintenance work compromises the comfort and health and safety of service users and must be done: the main shower at 159 needs repairing to ensure that the hot water supply is consistent and the shower cabin repaired; the radiator in a service users’ room (159) must be repaired; one service users’ street facing room (159) requires redecoration and windows need repairing; a keypad locked must be fitted to the front door of 159; a shower thermostat (159a) must be repaired; rubbish must be moved from the back garden of 159a and the kitchen floor seal (159a) needs fixing. Both managers said that cyclical redecoration has not been outstanding since July 2004. All of these maintenance issues are urgent and must be prioritised and completely quickly by the Norwood maintenance department. Requirements are given to cover these issues. Station Road 159-159a DS0000010532.V269969.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Service users benefit from competent staff teams who are clear about their roles and responsibilities. Staff training is programmatic and broad in scope. Gaps in adult protection training, addressed under Standard Twenty Three have been rectified. Sound supervision practice and effective management ensures staff are well supported while providing care to the service users. EVIDENCE: Both staff teams are relatively stable and staff said that their essentially new team at 159 had settled in and were working together very well. An additional twenty four hour position has been added to unit to increase the amount of time available for staff one to one sessions. 159a has recruited an new A grade staff member, providing additional management support. Files for new staff were inspected and contained all pre-employment checks. Both managers confirmed that, after a bumpy start, the cluster recruitment of staff from the Philippines has been successful, that the new staff have settled in very well and were supported by other staff in the home. Staff training, including an intense organisational induction, is well targeted and comprehensive. New staff described a full, formal induction process had said that they had received excellent support while learning the job. As part of Station Road 159-159a DS0000010532.V269969.R01.S.doc Version 5.0 Page 19 Norwood’s core training programme, staff are trained in manual handling, record keeping and communication, fire safety, first aid, risk assessment, understanding service user’s points of view, challenging behaviour, providing personal care, the Jewish way of life, autism, diabetes, epilepsy, adult protection, health and safety, first aid, food handling and adult protection. Staff training records confirmed that this training is regularly delivered and updated. A small gap in adult protection training identified at the last inspection has been covered and is addressed under Standard Eighteen. Staff in both houses are working through NVQ award study and there is allocated time for them to do this. All staff receive regular supervision, covering appropriate areas, which is documented and signed off. Regular staff meetings are held and minuted. Station Road 159-159a DS0000010532.V269969.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38 and 42 The registration of the houses as separate services is still in process but the homes are well run and the service users have not been disadvantaged. Service users are regularly consulted in an empowering way. General health and safety practice is good and fire safety recording and monitoring has improved. A magnetic doorstop must be fitted between the dining room and the kitchen of 159a. The organisation has sound business planning cycles and practices which need to be reflected at service level. EVIDENCE: There is no registered manager for the service. Each house has a manager and separate registration applications for each manager are pending, along with the application for registration of both homes as separate services. One manager has had her fit person interview and the other is still waiting for her Station Road 159-159a DS0000010532.V269969.R01.S.doc Version 5.0 Page 21 application to processed. Staff were very positive about the level of management support they received. Service user meetings are held monthly and, along with quality assurance working parties involving service users, are the main regular quality assurance tool currently in place. Fire records were reviewed. They are now kept up to date in both houses. Alarms are tested weekly. Fire equipment is regularly checked and serviced on contract. Six monthly evacuations involving service users should take place at 159a and at 159, there should be an unplanned evacuation every three months and a planned evacuation every six months. However, in 159, there has been no drill since April 2005, and this is required. The COSHH cupboard at 159 was unlocked an must be kept locked at all times to protect the service users. Accident and incident records were well kept and followed up. The organisational business plan is complete but the service still needs to produce its own, which is still required. Station Road 159-159a DS0000010532.V269969.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 2 3 X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Station Road 159-159a Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 X X X 2 2 DS0000010532.V269969.R01.S.doc Version 5.0 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. Standard YA6 YA20 Regulation 15(2) 13(2) Requirement The registered person must ensure that all care plans are regularly reviewed. The registered person must ensure that a written agreement is drawn up setting out the arrangements for staff to administer insulin to service users. Previous of 21/09/06 The registered person must ensure that the following maintenance work is completely urgently: • the main shower at 159 needs repairing to ensure that the hot water supply is consistent and the shower cabin repaired; the radiator in a service users’ room (159) must be repaired; one service users’ street facing room (159) requires redecoration and windows need repairing; a keypad locked must be fitted to the front door of 159; a shower thermostat Version 5.0 Page 24 Timescale for action 01/03/06 01/03/06 3. YA24 23(2) 01/03/06 • • • • Station Road 159-159a DS0000010532.V269969.R01.S.doc 4. 5. 6. YA42 YA42 YA43 23(4) 13(4) 25 (2) (159a) must be repaired; • rubbish must be moved from the back garden of 159a • the kitchen floor seal (159a) needs fixing; • A timetable redecoration plan must be submitted to CSCI The registered person must ensure that fire drill are carried out regularly in both units. The registered person must ensure that COSHH cupboards are kept locked at all times. The registered person must ensure that a business plan is produced for the service. Previous timescale of 01/11/05 not met. 01/03/06 01/03/06 01/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Station Road 159-159a DS0000010532.V269969.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Station Road 159-159a DS0000010532.V269969.R01.S.doc Version 5.0 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!