Inspection on 26/08/08 for Town Moor House

This is the latest available inspection report for this service, carried out on 26th August 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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Extracts from inspection reports are licensed from CQC, this page was updated on 13/11/2008.

CARE HOMES FOR OLDER PEOPLE Town Moor House 1 - 2 Town Moor Avenue Doncaster DN2 6BL Lead Inspector Valerie Hoyle Key Unannounced Inspection 26th August 2008 09:00 X10015.doc Version 1.40 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 Town Moor House DS0000071611.V370342.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 Older People. 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. Town Moor House DS0000071611.V370342.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Town Moor House Address 1 - 2 Town Moor Avenue Doncaster DN2 6BL 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) 01302 368573 01302367398 martindeakin@trustcare.co.uk Trust Care Limited Manager post vacant Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Town Moor House DS0000071611.V370342.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Old age, not falling with any other category - Code OP. The maximum number of service users who can be accommodated is: 25 First key inspection of the service 2. Date of last inspection Brief Description of the Service: Town Moor House is situated in a prominent position in Doncaster overlooking the open spaces of the towns playing fields. The home provides accommodation for 25 people. All are accommodated in single bedrooms. A number of bedrooms have ensuite facilities while others have toilet facilities close by. The home is divided into two main areas with lounges at both sides of the building. There is a passenger lift that accesses the first floor bedrooms, and there is a communal dining area in the centre of the home. There are gardens at the front of the home and there is also an enclosed yard at the rear of the building and a secure garden with garden furniture and flower tubs planted in the summer. The home was registered by the Commission for Social care inspection in April 2008 and the registered providers are Trust Care Limited. Information gained on the 26th August 2008 indicated the current fees range from £390.14 to £425.00 for residential care. Additional charges include private chiropody, hairdressing, and outings. The home provides information to service users and their relatives prior to admission into the home. Service Users Guides are available in all bedrooms or on request from the manager. Town Moor House DS0000071611.V370342.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means that the people who use this service experience good quality outcomes. This unannounced inspection was the first inspection of the service since being registered with CSCI in April 2008. Therefore all National Minimum Standards were looked at during this inspection. This unannounced inspection took place over 7 hours starting at 09:00 finishing at 16:00; this included a partial inspection of the home. A random unannounced inspection had taken place on 9th July 2008 to assess the arrangements within the home that support the safe handling of medicines. Helen Jackson Pharmacist Inspector accompanied the Link Inspector to check if requirements made at the random inspection had been met. Eight people who use the service, six relatives, four staff and a visiting district nurse were spoken to during the visit; their views were included throughout the report. Occupancy at this home has been consistently high. Twenty-three beds were occupied on the day of this inspection. Two peoples care plans were looked at. Policies relating to medication, complaints, protection of vulnerable adults and handling of people’s monies were looked at. Six staff recruitment and training records were looked at to assess how people were protected. Procedures and risk assessments relating to health and safety were looked at and discussed with the manager. The manager is Anita Cooper, she holds a relevant NVQ qualification and the Registered Managers Award (RMA) and has a wealth of knowledge working with older people in the care setting. She has only recently been appointed and had taken up her position as manager on the day of this inspection. She has been registered with the Commission for Social Care Inspection prior to taking this position and the registered providers intend for her to be the registered manager at Town Moor House. The AQAA was sent to the home in July 2008, this was returned to us on time, which demonstrates responsiveness and cooperation. An annual quality assurance assessment (AQAA) is a self-assessment and a dataset that is filled in once a year by all providers whatever their quality Town Moor House DS0000071611.V370342.R01.S.doc Version 5.2 Page 6 rating. It is one of the main ways that we will get information from providers about how they are meeting outcomes for people using their service. The AQAA also provides us with statistical information about the individual service and trends and patterns in social care. The inspector would like to thank everyone who agreed to being interviewed as part of the inspection process, and the friendliness of staff. What the service does well: What has improved since the last inspection? The pharmacist inspector found evidence of significant improvements in practice. There are good systems in place for the accurate administration and recording of medicines. This means people are receiving their medication safely and as prescribed. Town Moor House DS0000071611.V370342.R01.S.doc Version 5.2 Page 7 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. Town Moor House DS0000071611.V370342.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Town Moor House DS0000071611.V370342.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5, 6, People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service were assessed before moving into the home to ensure their needs could be met. People receive the information they need to make decisions about the service. EVIDENCE: The registered providers have developed a Statement of Purpose and Service User Guide which was good quality. They provide information written in plain English which describes services and philosophies of care at the home. People confirmed that they have access to quality information, and relatives said they had looked at the new information in the entrance of the home which was very good. Relatives said they had the opportunity of meeting the new providers informally when they took over the home. They said that they had Town Moor House DS0000071611.V370342.R01.S.doc Version 5.2 Page 10 improved the quality of care, and the environment from taking over the running of the home. People have retained contracts established on their admission and the registered providers confirmed that most people were placed by the local Social services department. All new people admitted into the home will receive a contract issued by the new registered providers. All new people receive a full comprehensive needs assessment before admission; this was carried out by the manager who had the required skills and competencies. The service was efficient in obtaining a summary of assessments undertaken by the placing authority, and insists on receiving a copy of the care plan before admission. Staff confirmed that information contained in the assessment was essential to understand what they needed to do to ensure people’s needs were met. Two assessments were looked at and they focused on achieving outcomes for people who use the service. A newly admitted person to the home had basic details recorded. This could be improved to assist in forming the care plan. Before agreeing admission the manager would carefully considers the needs assessment for each individual prospective person and the capacity of the home to meet their needs. Relatives said they had looked at a number of homes and were happy with the way Town Moor House cares for their relative. They said staff were very supportive and answered all their questions when they came to look around the home. Intermediate Care was not provided at the home. Town Moor House DS0000071611.V370342.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care that people receive was based on their individual needs. The principles of respect, dignity and privacy were put into practice. Medication procedures were well managed by staff that has the necessary competencies. EVIDENCE: The manager said the care plans were being transferred onto the registered provider’s documentation. Care plans were looked at to ensure care was delivered as described. The information was sufficient although some details had not been completed. One persons care needs had changed, and the care plan had been updated in part but the nutritional assessment did not reflect the person current needs. There were inconsistencies in the way the food/fluid intake charts had been completed which means the person’s nutritional needs may not be met. One new persons care plan had not been fully completed although letters (dietician) and assessments clearly identified that the person had multiple care needs. Details on Weight, nutrition, and the person’s mental Town Moor House DS0000071611.V370342.R01.S.doc Version 5.2 Page 12 health needs must be completed as soon as practicable after admission to ensure they are not put at risk. Staff was provided with support from district nurses to meet people’s healthcare needs. A visiting nurse said staff informed the district nursing service if they had any concerns about people who use the service. Assistance with skin care, dressing and taking bloods were some of the tasks undertaken by the nurse. Relatives said staff kept them informed of changes to their relatives care. They said staff were kind and caring and they knew the resident’s and what they need. Staff respect privacy and dignity and were sensitive to changing needs, relatives confirmed that staff speak to people in a respectful manner and were kind and caring. The recording of medicine administration is good. There were no gaps on the MAR charts indicating medicines are given as intended. Good, detailed records are made on the chart to explain why medication has not been given. A record is made of all medication supplied and the date received. The quantity of medication from one monthly cycle to another is recorded on the new MAR. This means there is a complete record of medication within the home and helps when checking if medication is being administered correctly. Handwritten entries on the MAR were well written. It is important to have accurate entries to make sure people get their medication correctly. An audit of current stock and records showed that medication is being administered as prescribed. It is important that medication is given as prescribed to make sure a person’s medical condition is treated correctly. One person has an injection administered by a member of the district nurse team. This medication is a controlled drug and the supply is recorded in the controlled drug register in the care home. However a member of the senior care staff rather than the district nurse makes a record of administration in the register. The register must accurately record the use of this controlled drug and therefore must record that administration is by the district nurse. A record of the quantity of controlled drug returned is not made. This means that there is not a complete and accurate record of controlled drugs entering and leaving the home. A number of people self administer their medication but there is currently no risk assessments in place. The care plans are currently being updated and it is important that they include an assessment on whether that person is able to Town Moor House DS0000071611.V370342.R01.S.doc Version 5.2 Page 13 take their medication as prescribed and is happy to do so. This is of particular importance for one person who is prescribed eight different medicines. Town Moor House DS0000071611.V370342.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are able to socialise with family and friends and mealtimes were well managed. EVIDENCE: The registered providers had spent time developing relationships with relatives and the people who use the service. Two meetings have taken place and the relatives were very complimentary about the changes that the providers had introduced. Relatives said “they listen to what we have to say, and have carried out changes to make the home a better place for people to live”. People said “they seem very nice and one of the owners came on a recent trip to Skegness, we enjoyed the trip very much”. Visiting arrangements at the home was flexible and relatives said, “staff made them feel welcome and staff had time for a chat about the care of their relative”. Town Moor House DS0000071611.V370342.R01.S.doc Version 5.2 Page 15 Arrangement for people to take part in activities was limited, there was an activity schedule but there was no evidence to confirm activities had taken place. Care plans did not include an activity plan, although one member of staff said he made the entry on the daily notes which described when a person had joined in activities. People said they spent time reading books and watching TV, but did not join in anything organised by the home. The AQAA received has identified activities as a area requiring further development and they plan to make improvements in the next 12 months. Mealtime were well organised and staff were available to give assistance. There was a choice of main and sweet courses although the meal of cornish pasties and chips looked quite dry. Gravy was not offered although other condiments were available on the table. People said they had enjoyed their lunch, and said the food was generally quite good. Town Moor House DS0000071611.V370342.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service were able to express their concerns, and have access to a robust, effective complaints procedure, and were protected from abuse, and had their rights protected. EVIDENCE: The home had a complaints procedure that was available to people and visitors. The procedure was also referred to in the information given to new people, identifying the stages to follow; this includes the time scales to respond to complaints. The address and telephone number of the Commission for Social Care Inspection was included in the procedure. Information contained in the AQAA (Annual Quality Assurance Assessment) confirmed that one complaint had been made in the last twelve months. Records were looked at and they confirmed that procedures were followed, and action was taken to resolve the complaint. Relatives confirmed that they were aware of the complaints procedure and who to speak to if they had a concern. People said “I am confident that the new providers would deal quickly with any problems I may have”. “If I have complained they deal with it and we get on with things, we try to live together as friends”. The policies and procedures regarding safeguarding of people were of a good quality and were regularly reviewed and updated. The manager was able to confirm that staff had received training to identify signs of abuse. New starters Town Moor House DS0000071611.V370342.R01.S.doc Version 5.2 Page 17 still require formal training which will be delivered from the manager in the near future. The registered providers were clear when incidents need external input including who to refer the incident to. They had promptly followed referral procedures to inform the relevant agencies about two incidents that had been raised at the home. The referrals have not yet been concluded and remain under investigation. Procedures have been followed to ensure people’s safety until the investigation process is concluded. Town Moor House DS0000071611.V370342.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service are provided with a clean, comfortable environment and there were sufficient staff to maintain good hygiene standards. EVIDENCE: The home provides a physical environment that is appropriate to the specific needs of the people who live at the home. People who use the service said, “they like living at the home and it is always kept clean”. They are able to bring in personal items from home to make their room feel like home. The registered providers have developed a refurbishment plan which has included landscaping the front garden to make it a pleasant area for people to sit. They have refurbished 2 people’s bedrooms, fitted new carpets in the Town Moor House DS0000071611.V370342.R01.S.doc Version 5.2 Page 19 entrance and blinds in the lounges. New equipment in the kitchen, and laundry means that staff were able to maintain good hygiene standards. The home was clean and fresh and staff have had training in the control of infection to ensure service users are protected. The domestic staff are commended for their efforts in maintaining the cleanliness of the home. Relatives said that the home was always clean and fresh. Town Moor House DS0000071611.V370342.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff in the home were trained, skilled and in sufficient numbers to support the people who use the service, in line with their terms and conditions, and to support the smooth running of the service. EVIDENCE: Staff was employed in sufficient numbers and skill mix to ensure the safety of people who use the service. Staff rotas were looked at confirming adequate levels. Since the last inspection there had been a number of changes to the staff group. New staff had integrated well with more experienced staff. It was pleasing to hear from a number of relatives who said the staff was caring and friendly. The staffing structure includes senior carers, carers and domestic staff. There was a senior carer on duty during the day who has responsibility to administer medication, although during the night, no staff was designated as senior. It is important the someone is designated as senior on each shift to take lead responsibility in cases of emergency. Recruitment and selection procedure were robust and ensure people who work at the home have the right qualities and skills. Six staff files were examined and they contained all the required employment checks, including CRB (Criminal Records Bureau) POVA (Protection of Vulnerable Adults) and Town Moor House DS0000071611.V370342.R01.S.doc Version 5.2 Page 21 references. A new staff confirmed that he had been asked to provide references and attend an interview. The registered providers intend to register with ‘Skills for Care’ and use there induction programme. Training continues to be ongoing for all staff at the home. Most recent training has included fire safety, moving and handling and pressure area care. Staff were also involved in National Vocational Qualification (NVQ) training. The numbers of staff trained to level 2 NVQ in care exceeded the minimum 50 required. A further three staff continue to work towards attaining the NVQ award. Town Moor House DS0000071611.V370342.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37, 38 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service were protected by sound management practises, and their views were actively sought to improve the service. The financial interests of people were safeguarded, and good health and safety procedures ensured they are protected. EVIDENCE: The registered providers have been responsible for the day to day running of the home following the resignation of the registered manager. Relatives and people who use the service were very complementary about how they had improved the service. They have appointed a new manager Anita Cooper who had taken up her post on the day of this inspection. She has the required qualifications and the skills needed to manage the home. Town Moor House DS0000071611.V370342.R01.S.doc Version 5.2 Page 23 The registered providers have held formal supervision with all staff to establish their skills and competencies, it is their intention that the manager will take over the responsibility once she has settled into her position. The providers had held meetings to introduce themselves and to seek the views of people who use the service. They have also developed a quality assurance questionnaire, although it has not been tested. They intend to send out the surveys in the near future. Consideration should be given to the format to enable people to give comments about the service after each question. Surveys for relatives and professionals should also be developed. Accident reports were analysed by the manager to ensure risk assessments was developed where required. Maintenance and service records looked at were up to date and current to the services provided. The manager has the required Health and Safety policies and procedures and displays the relevant notices. People who use the service are able to manage their own finances, although some prefer the manager to assist with dealing with their personal allowances. A number of peoples personal allowance records were examined and checked, the records were accurate and there were clear auditing procedures. Town Moor House DS0000071611.V370342.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Town Moor House DS0000071611.V370342.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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 OP7 Regulation 15 Requirement Care plans must be updated to reflect the current needs of the person including nutrition, weight and mental health needs. Food and fluid intake charts must be consistently completed. This will make sure that the person’s healthcare needs can be monitored. Care plans must be fully completed as soon as practicable after admission into the home. Timescale for action 01/09/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations The temperature of the medication room should be regularly monitored. This makes sure that medicines are being stored at the temperature recommended by the manufacturers. Town Moor House DS0000071611.V370342.R01.S.doc Version 5.2 Page 26 2. OP9 The recording of controlled drugs must be accurate and consistent. This makes sure there is a complete record of these drugs entering and leaving the home. The appointment of an activity co-ordinator should be considered to ensure people can access a range of activities. Records (on care plans) should be kept to demonstrate what activities have taken place. A designated senior should be identified to be on duty during the night. They should have responsibility for acting in case of any emergency. The new manager should submit an application to CSCI to be the registered manager within three months of her appointment. Quality assurance surveys should be developed for stakeholders and relatives. People who use the service should be surveys as soon as practicable to give them the opportunity to give their views on the service. The data received should be analysed and formulate an action plan to improve the service. 3. OP12 4. OP27 5. OP31 6. OP33 Town Moor House DS0000071611.V370342.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Eastern Region 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 Town Moor House DS0000071611.V370342.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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