Inspection on 27/11/06 for Tennyson Road, 104

This inspection was carried out on 27th November 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Tennyson Road, 104 19/11/08

Tennyson Road, 104 28/12/07

Tennyson Road, 104 20/04/07

Tennyson Road, 104 28/10/05

Tennyson Road, 104 17/06/05

Tennyson Road, 104 12/03/05

Tennyson Road, 104 14/09/04

Tennyson Road, 104 06/03/04

Similar services:

Chesham House

Argyll House

Dorset Lodge

Acacia House

Falcon House

Dial House Nursing Home

Cromwell Avenue (9)

Abbey Lodge

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

CARE HOME ADULTS 18-65 Tennyson Road, 104 Luton LU1 3RP Lead Inspector Katrina Derbyshire Unannounced Inspection 27th November 2006 11:30 Tennyson Road, 104 DS0000014977.V320780.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 Tennyson Road, 104 DS0000014977.V320780.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. Tennyson Road, 104 DS0000014977.V320780.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tennyson Road, 104 Address Luton LU1 3RP 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) 01582 418858 Mr Geoffrey Plane Miss Deborah Newman Mr Gerard Kempson Care Home 8 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (8) of places Tennyson Road, 104 DS0000014977.V320780.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th October 2005 Brief Description of the Service: 104 Tennyson Road is a care home which is registered for a maximum of eight adults with mental health needs. The accommodation consists of a three storey house with eight single bedrooms. The office is on the ground floor. It also has sleeping in facilities for staff (including en suite facilities). The lounge, dining room and the kitchen are also located on the ground floor. The laundry room is located at the back of the house and accessed via the kitchen. There is a small parking space at the front and a garden at the back. The rear garden is secluded and has some shrubs, trees, flowerbeds and a small patio area with a barbeque. The home is situated approximately one kilometre from the shopping centre of Luton. A bus stop is located within walking distance of the home. There is a regular bus service to the town centre. The fees for this home vary from £400.00 per week for residential placements, to £600.00 per week. Tennyson Road, 104 DS0000014977.V320780.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was to undertake a key inspection. This unannounced inspection was carried out on 27th November 2006. The Registered manager and associate manager were present throughout the inspection. During the inspection areas of the home were visited and the inspector spent time with residents’ mainly in the ground floor sitting area of the home. The care of three residents’ was examined by looking at their records and interviewing the residents’ and staff who look after them. The views of residents and their feedback have been used alongside information from the home through written evidence to assess the outcomes within each standard. Evidence used and judgements made within the main body of the report include information from this visit. Evidence used and judgements made within the main body of the report include information from this visit and the random inspection carried out in May 2006. Observations of care practice and communication between the residents’ and staff was also made at the inspection. The focus of this inspection was to look at the key standards and to follow up on previous requirements. What the service does well: The staff at the home continue to work together as a team and communicate with each other very well, they have worked this way for many years. They all meet regularly for staff meetings and make sure that they all know about the support that is needed by the residents. This means that the care received by residents’ is always consistent. Also some of the staff at the home have a very good level of knowledge and understanding of the needs of the residents. They know about the individual needs of the resident, their likes and dislikes and about their friends and families. Several residents spoke of how important this was to them as it made them feel that the staff cared about them. There is also a very relaxed atmosphere in the home; many of the residents spoke of feeling “relaxed and feeling very comfortable” living at the home. Residents spoke of the staff’s friendliness and felt that it was this that made them feel at ease. Tennyson Road, 104 DS0000014977.V320780.R01.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. Tennyson Road, 104 DS0000014977.V320780.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 Tennyson Road, 104 DS0000014977.V320780.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of pre admission assessment at this home is good so management have sufficient information to ascertain if they are able to meet the needs of the residents. EVIDENCE: Information seen within the care records of residents showed that a system was in place to assess the needs of prospective residents. The home was noted to use a standardised document to record their assessment of needs. In addition information from the referring agency was also seen providing a comprehensive background concerning the resident’s life. Residents are invited to visit before deciding to move in to the home, meals can be taken and there is a possibility of an overnight stay. One resident confirmed that they had been given a choice as to whether they moved into the home. They also recollected being asked to give their views about their own needs and how they felt staff could support them in meeting their needs. Tennyson Road, 104 DS0000014977.V320780.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 & 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of care planning at this home is good, providing staff with clear guidance on how they should support the residents to meet their individual needs. EVIDENCE: The home maintains care plans on each of the residents; each care plan is directly linked to the assessments undertaken so that there is a plan in place, for each assessed need. Care plans set out any rehabilitation plans or communication development for the resident, and were clear in any restrictions on choice or freedom in place following a detailed risk assessment. Residents were aware of the care plans and spoke of their involvement supported by staff in their development. However the homes own policy to review the care of each resident every six months had not been undertaken for all residents. Tennyson Road, 104 DS0000014977.V320780.R01.S.doc Version 5.2 Page 10 Residents through discussion confirmed that they liked living in the home and felt their privacy was respected. Management had sought the services of an advocacy group for those residents who did not have any other representation. Documents that described varying activities undertaken by residents were seen. The activity had been described and it gave clear guidance on the required support needed for each resident, so that any risk associated with that activity would be reduced. Risk assessments were also in place on individual files relating to fire safety associated with smoking, and the physical support required by the resident. Observation of the physical and emotional support offered to one resident during the inspection so that the risk to that resident was reduced was noted to be carried out appropriately, this support had been described in the residents records. Tennyson Road, 104 DS0000014977.V320780.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): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The support available to residents from staff at this home is sufficient for them to maintain and develop family and other close relationships in their lives. EVIDENCE: A choice of meals was available; menus seen examined reflected a varied diet and staff informed the inspector that residents were involved in setting the menus in the home and on occasions assisted in the homes ‘ shopping’. The kitchen was seen to be clean and tidy and the documentation regarding kitchen cleaning, food labelling and temperature control were all noted to be satisfactory. Residents through discussion and through feedback from returned comment cards confirmed that they were satisfied with the food at the home. However no nutritional risk assessments were seen on the resident’s files at this inspection. Several residents whom had been diagnosed with a medical Tennyson Road, 104 DS0000014977.V320780.R01.S.doc Version 5.2 Page 12 condition that affects their ability to gain and lose weight live at the home. The need for a nutritional risk assessment will be subject to a requirement to ensure that the nutritional needs of all residents are assessed and regularly reviewed to ensure the nutrition plans of the residents are in accordance with their assessed needs. One resident spoke of the contact with their family, they were visited by their family members at the home on a regular basis or they could visit them at their own home. Documents seen within the individual care record of this resident gave clear guidance to staff in how they should support the resident in maintaining these close relationships with the family members. Management advised that none of the resident’s were engaged in paid employment at this time. Residents through discussion spoke of their attendance at a local centre and described their programme of learning. Information examined supported this as records were maintained to show that one resident for example had received help with financial management. Entries made within the care records described the social and leisure activities the resident’s had received. Records viewed on the day of inspection indicated that activities that had been provided for example were shopping trips, walks and going out for a pub meal/drink. One resident who was able to access local facilities independently did so several times each week, they informed the inspector that they liked to go to the local bingo hall. The care records seen also identified very different individual interests of the residents and they were specific in the identification of the residents preferred leisure interests, regular contact with family members and visits to their homes were also included. Residents spoke of their favourite things that they liked to do and these included for one resident an interest in music; which they had access to in their rooms with audio equipment in place. Tennyson Road, 104 DS0000014977.V320780.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 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The way in which the medication at the home is managed continues to be satisfactory in promoting good health for the residents. EVIDENCE: All residents are registered with a General Practitioner and access to any other needed healthcare service, would be made following a referral by the residents General Practitioner. However one resident receiving care and support from a range of medical staff relating to a medical need had no entries made, onto their document that the home should maintain to show when a medical professional had visited. Therefore it was unclear if and when care had been offered to this resident who requires considerable support. In addition other residents medical support documents had no entries made since 2005. This was discussed with management in the home and the need to make clear the attendance, consultation and outcomes of healthcare appointments. Tennyson Road, 104 DS0000014977.V320780.R01.S.doc Version 5.2 Page 14 As assessed at a previous inspection medication is stored in a locked cabinet, as there are currently no controlled medication within the home the current storage facilities are satisfactory. Medication charts are kept for each resident and staff sign each time a medication is administered, the use of a monitored dosage system is used. Staff confirmed that they had received training in the administration of medication. On inspection the receipt, recording, storage and handling of medication were appropriately carried out. Through discussions with both residents and staff the inspector was informed that times for getting up or going to bed were led by the residents, restrictions that were in place for example to rise at a certain time to attend another service during the day were documented in the care records seen on this inspection, and the reasons for these restrictions were made clear. It was observed that only once permission from a resident had been given, did staff enter service resident’s individual rooms. Also through discussion with residents they confirmed that they choose their own clothes and hairstyle. Guidance and support regarding personal hygiene and the level offered by staff was reflected in the care plans examined on this inspection. Tennyson Road, 104 DS0000014977.V320780.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 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems in place for the management of complaints continue to be satisfactory so residents feel that their concerns are listened to and acted upon. However the internal guidance for the reporting procedures under the protection of vulnerable adults at the home is not sufficient to ensure the residents are being protected at all times. EVIDENCE: The training profiles of staff showed that they had attended training in the protection of vulnerable adults this was supported by staff at interview. On requesting the homes policy and reporting procedure at this visit, management at that time had in place a policy that gave information on the types of abuse and how staff could possibly recognise the abuse of a vulnerable adult. However the reporting procedures in the event of any suspicion or allegation of abuse was not clear and did not reflect the local guidance on how an allegation or suspicion of abuse should be managed. A requirement has been made in relation to this area so that both management and staff know how and when to report abuse and their role in any subsequent investigation. As reported at the random inspection in May 2006 records relating to the receipt and investigation of complaints were examined as a requirement had been made at a previous inspection. Clearer recording tools were seen to be in place and those records examined demonstrated that complaints had now been Tennyson Road, 104 DS0000014977.V320780.R01.S.doc Version 5.2 Page 16 investigated and a record of the outcome was in place. No further complaints had been received by the home since that inspection. Comments cards received from residents showed that they knew how to complain and felt comfortable in doing so. Tennyson Road, 104 DS0000014977.V320780.R01.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 & 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The general maintenance of the environment and furnishings in some areas of the home continues to be of a poor standard, although this does not place the residents at risk it does not create a pleasing and pleasant environment to live in. EVIDENCE: As reported at the random inspection in May 2006 the carpet in the main lounge had been cleaned following a previous requirement, however it remained stained and worn looking. The home must consider replacing this area of flooring with an alternative appropriate covering; this was discussed again with management at the time of this inspection. The replacement of the hall carpet had taken place and decoration of one resident individual room had occurred earlier in the year. However several areas in the home require re decoration including the dining area at the home, no curtains were in place in Tennyson Road, 104 DS0000014977.V320780.R01.S.doc Version 5.2 Page 18 this room. It was noted that although the sitting area of the home was tidy, tables in this area were stained and the varnish was peeling off. Other furniture in this area was chipped and worn and replacement of these items are required to ensure residents have a homely environment in which to live in. Other areas in the home were also seen to require improvements including the staff facilities and bathrooms both of which had broken fittings, raised flooring and chipped tiling. The standard of cleanliness in the home was seen to have improved since the last inspection. Management advised the appointment of a housekeeping member of staff had taken place. Tennyson Road, 104 DS0000014977.V320780.R01.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 & 35 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Systems in place for the recruitment of staff are not sufficient to protect residents and places them at risk. EVIDENCE: Examination of staff files was carried out to view recruitment practices in the home. The most recent staff member to be employed at the home had started work prior to the home securing a criminal records bureau check. This had been raised at a previous inspection and then complied with, therefore management in the home were fully aware of the regulations and guidance on this matter. This is not acceptable practice and places the residents at risk. One staff member was on duty alongside the management in the home. On interviewing this staff member they demonstrated a very good level of knowledge and understanding of the residents and their needs. They were able to describe the information contained within the residents care plan and how they should provide care and support. Tennyson Road, 104 DS0000014977.V320780.R01.S.doc Version 5.2 Page 20 Training records viewed showed that staff had received training specific to their roles including managing violence and aggression, understanding mental health, administration of medication and risk assessment. Staff confirmed that the home supported them in undertaking training. Views received from residents through the comment cards show that they feel staff are able to meet their needs most of the time; they also feel that they are able to talk to them and staff will listen. Tennyson Road, 104 DS0000014977.V320780.R01.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 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements are needed to ensure Health and Safety systems are sufficient to reduce risks of accidents to residents. EVIDENCE: The Registered manager of the home has reduced their weekly working hours; this will be a long-term arrangement. The Deputy manager in the home works full time and it is the homes intention that when they complete their Registered Managers Award in 2007, that they will submit an application to the Commission for Social Care Inspection to become the Registered Manager for the home. On interviewing a staff member they stated that the current management arrangements were “okay, you can ask them both anything really Tennyson Road, 104 DS0000014977.V320780.R01.S.doc Version 5.2 Page 22 we still feel supported”. Residents in the home supported this feeding back that they found both people approachable. The Deputy Manager advised that the home held residents meetings to seek the views of the residents, minutes of these meetings are available for inspection. However she confirmed that the home had not undertaken an annual development plan using the views of residents, thus these results had not been published and made available to the residents and other interested parties. A requirement is made relating to this. Staff and training records showed that they had undertaken training relating to health and safety matters, including fire safety and food hygiene. Fire safety checks were undertaken alongside food temperature checks. However the systems in place for controlling the temperature of the water were insufficient, no mixer valves are in place within the bathroom and no temperature checks are undertaken. A requirement is made relating to this. Tennyson Road, 104 DS0000014977.V320780.R01.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 2 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 3 32 X 33 X 34 1 35 X 36 3 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 3 14 X 15 3 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 X 3 X X 3 X Tennyson Road, 104 DS0000014977.V320780.R01.S.doc Version 5.2 Page 24 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA17 Regulation (17)(1)(a) Schedule 3 (m) Requirement Nutritional risk assessments must be undertaken to make certain the nutrition plans of residents are in accordance with their assessed needs. The home must ensure that a record is maintained of all health care support provided for residents. The homes policy and guidance on the Protection of Vulnerable Adults must include the referral methods as directed in the local joint policy in this matter. The carpet in the lounge must be replaced with a suitable alternative covering. (Previous requirement timescale of 30/09/06 not met) Bedroom carpets with heavy stains and burns must be replaced. (Previous requirement timescale of 15/12/05 & 31/07/06 not met) DS0000014977.V320780.R01.S.doc Timescale for action 31/01/07 2. YA19 12, 13 & 15 31/12/06 3. YA23 12 & 13 31/01/07 4. YA24 23(2)(d) 28/02/07 5. YA24 23(2)(d) 28/02/07 Tennyson Road, 104 Version 5.2 Page 25 6. YA24 23(2)(d) 7. YA30 23(2)(d) Repair or replacement of 31/03/07 worn fittings, flooring and furniture in the home must be carried out. The registered persons must 31/01/07 ensure that the home is kept clean and hygienic. (Previous requirement timescale of 28/12/05 not met, timescale of 30/06/06 only partially met) The home must secure a criminal records bureau check on staff prior to their commencement in the home. A quality assurance system must be implemented. This must seek the views of service users, their relatives and other professionals. A report of the findings and any recommendations must be compiled and made available to the CSCI. (Previous requirement timescale of 28/01/05 & 31/08/06 not met) 31/12/06 8. YA34 12, 13 & 19 Sch 2 9. YA39 24 31/01/07 10. YA42 12 & 13 The home must implement 31/12/06 systems to ensure sufficient safety measures are in place to reduce the risk of scalding from hot water. 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 Tennyson Road, 104 DS0000014977.V320780.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 Tennyson Road, 104 DS0000014977.V320780.R01.S.doc Version 5.2 Page 27 - 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!