Inspection on 04/12/06 for 13a Green Lane

This inspection was carried out on 4th December 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

13a Green Lane 10/03/06

13a Green Lane 15/08/05

13a Green Lane 14/10/04

13a Green Lane 24/04/04

13a Green Lane 29/06/03

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 13a Green Lane 13A Green Lane Leigh Wigan Greater Manchester WN7 2TL Lead Inspector Lynn Sharples Unannounced Inspection 4th December 2006 09:30 13a Green Lane DS0000035964.V315589.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 13a Green Lane DS0000035964.V315589.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. 13a Green Lane DS0000035964.V315589.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 13a Green Lane Address 13A Green Lane Leigh Wigan Greater Manchester WN7 2TL 01942 673511 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) Wigan Council Social Services Department Jennifer Ann Mills Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 13a Green Lane DS0000035964.V315589.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home is registered for a maximum of 5 service users to include:up to 5 service users in the category of LD (Learning Disability) The service should at all times employ a suitably qualified and experienced manager who is registered with the CSCI The Registered Manager must spend a proportion of their working hours each week on site to have a clear present in the home, to oversee the running of the home, and supervision of care staff on the premises, to include weekends and times when the service users are presence in the home. This must be reflected on records maintained in the premises. Staffing levels are to be calculated in accordance with the Residential Forum Staffing Guidance (Older People and Younger Adults) by 1 April 2004. 10th March 2006 4. Date of last inspection Brief Description of the Service: 13a Green Lane is a Local Authority care home, providing a short term break service for five people, over the age of eighteen, who have a learning disability. The home is situated in Leigh close to local shops and amenities. The home is set back from the road and is reached via a long driveway, there is parking to the front of the home and gardens to the side and rear. There are five bedrooms, a kitchen, lounge, lounge/dining room, shower room and two bathrooms with toilet facilities. The fees for the short term break service are between £10 - £40.66 per night. 13a Green Lane DS0000035964.V315589.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. At the time of the visit there were two people staying at the short beak service. The home did not know about the visit and it took three hours. Service users, the manager and the care staff were spoken with; completed comment cards were received from relatives. The files relating to the service users, staff and the home were read and the premises toured. What the service does well: The homes Statement of Purpose and Service User Guide are comprehensive providing service users and prospective service users with details of the services the home provides enabling an informed decision about the admission to the home. Prospective service users’ individual needs are assessed ensuring that the home can meet their needs. The care plans ensure that the service users individual needs are met and that service users can make choices. This ensures that service users can make decisions about their lives with assistance as needed. Service users engage in community and leisure activities appropriate to their needs and wishes and this ensures that service users are stimulated whilst staying at the home. Dietary needs of service users are well catered for with a balanced and varied selection of food available that meets service users tastes and choices. One service user explained that they like to draw and was happy to show their artwork. There is clear, consistent care planning system in place to provide staff with the information they need to meet service users needs. One plan said, “ I usually go to bed at 10pm and I like to have two pillows.” The home has a documented complaints procedure to ensure residents’ views are listened to and acted upon. Systems are in place to ensure residents are safeguarded from abuse and harm. The standard of the environment within the short break service is good providing service users with an attractive and homely place to stay. There were fresh flowers in vases and modern pictures on the walls creating a homely environment. The recruitment practices are good and appropriate checks are carried out. This ensures that the resident is not put at risk. The staff training provided ensures that the staff are equipped to meet the needs of the service users. Comment cards received from relatives said “ Staff have always been very helpful” and that it “ seems a very happy atmosphere when I have called.” Also, “ staff are always willing to help you and are welcoming.” A comment card said that, “ the manager has done so much for us and is very understanding.” 13a Green Lane DS0000035964.V315589.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. 13a Green Lane DS0000035964.V315589.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 13a Green Lane DS0000035964.V315589.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 1,2,4 The homes Statement of Purpose and Service User Guide are comprehensive providing service users and prospective service users with details of the services the home provides enabling an informed decision about the admission to the home. Prospective service users’ individual needs are assessed ensuring that the home can meet their needs. EVIDENCE: The Statement of Purpose is detailed and contains all the information a service user and carer would need to make an informed choice about whether to stay at the home. The Service User Guide is also presented in a pictorial form and gives services users all they need to know about the service and is a good informative document. Prior to staying at the home a social worker completes a need led assessment/ care plan. The team then has a referral meeting to establish if the home can meet the needs of the service user. If this is agreed, the social worker is notified and the service user and family are invited to look round and look at the Statement of Purpose. If the service user wants to stay, the manager visits the service user at home and help notes are completed with the service user and their family. The help notes are an assessment of need and assessment of 13a Green Lane DS0000035964.V315589.R01.S.doc Version 5.2 Page 9 the service users wishes, which include: - personal and medical information, a personal profile, including cultural needs, interests, communication, eating and drinking, health and safety. The home then individually plans introductions to the home. This usually takes the form of a visit in the evening and a meal with other service users and staff this occurs a few times and then one over night stay is arranged and then a weekend stay to gradually introduce serviced users to the short break service. 13a Green Lane DS0000035964.V315589.R01.S.doc Version 5.2 Page 10 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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. 6,7,9 The care plans ensure that the service users individual needs are met and that service users can make choices. This ensures that service users can make decisions about their lives with assistance as needed. The risk assessments are brief and do not protect the service users from harm. EVIDENCE: The two care plans looked at contained assessments, care plans, key information sheets, help notes and reviews. These included information such as, “ I do not need assistance with bathing” and “ I will tell you if I dislike anything”. There is also a service agreement that were possible is signed by the service user and is presented in a pictorial format. The care plans are reviewed on a regular basis either six or twelve months by the social worker and the service user, relative or representative and the 13a Green Lane DS0000035964.V315589.R01.S.doc Version 5.2 Page 11 homes manager attend. The help notes are also reviewed regularly and involve the key worker, service user and their relative or representative. The service users make decisions in terms of the food they wish to eat, the clothes they wear and the activities they want to participate in. The care files included details such as, “ I let you know what I want with gestures.” The service users can were possible chose which bedroom they want to use during their stay. The care files included risk assessments and these are personalised and assess the risk of the activity and of the building in relation to each individual. One service user had a diagnosis of epilepsy and should have a risk management strategy relating to this to ensure that the care staff know what to do if the service user has a seizure. The risk assessments were brief and did not include all the information a carer would need to fully support a service user in all aspects of their care. The risk assessments are reviewed regularly at least every six months. 13a Green Lane DS0000035964.V315589.R01.S.doc Version 5.2 Page 12 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 12,13,14,15,16,17 Service users engage in community and leisure activities appropriate to their needs and wishes and this ensures that service users are stimulated whilst staying at the home. Dietary needs of service users are well catered for with a balanced and varied selection of food available that meets service users tastes and choices. EVIDENCE: During the day most service user attend a day service and consequently prefer to relax in the evenings during the week. One service user explained that they like to draw and was happy to show their artwork. Each bedroom has a television so that service users can watch this in private if they wish to. There are also two televisions downstairs so that service users can watch different programmes if they wish and socialise in the two rooms. The care staff said that at the weekends the service users go out to visit places of interest, care 13a Green Lane DS0000035964.V315589.R01.S.doc Version 5.2 Page 13 boot sales and markets, pub lunches and trips to Blackpool. The diary details the trips planned and the service users spoken with said that they enjoy going out. One survey suggested that service users would like to go out more and to shopping complexes. There was evidence that public transport was used, the home does not have its own transport. Service users are encouraged and supported to maintain links with their family and friends during their stays at the service. During the visit family members contacted the home and a service users who uses the service rang for a chat. The short beak service hold a coffee morning for family and friends twice a year, there were fliers in the home to indicate that one was to be held the next day. This was an opportunity to discuss any changes, concerns and share information in an informal setting. The care staff were observed knocking on people bedrooms door before entering and observed talking with service users and interacting appropriately. The service does not have a set routine. It is flexible to ensure that the service meets the differing needs and preferences of the service users. The rules on smoking are stated in the service agreement. There are no set menus this is decided by the service users staying at the short break service. Service users nutritional needs are assessed and reviewed including risk factors associated with low weight, obesity and eating and drinking disorders. The evening meal was fish, mashed potatoes, beans and a hot dessert. The meals eaten are recorded in the daily records sheet. The mealtime was relaxed and unhurried with the care staff eating with the service users, to make this a pleasant experience for the service users. 13a Green Lane DS0000035964.V315589.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 18,19,20 There is clear, consistent care planning system in place to provide staff with the information they need to meet service users needs. The lack of assessment of the bedsides leaves the service users at risk of harm. The medication at this home is well managed promoting good health. EVIDENCE: The care plans indicated a service users preference about how they are supported and this recorded. One plan said, “ I usually go to bed at 10pm and I like to have two pillows.” Times for going to bed were flexible. Some beds had bedsides attached and these are serviced every six months, however, the home does not always consult an occupational therapist when these are used. This was discussed with the manager who said that they would contact an occupational therapist to ensure that the service users who use the bedsides are safe and that this is included in the risk assessment. The service users health needs are monitored whilst at the home and included in the care plans. Some service users have Health Action Plans. 13a Green Lane DS0000035964.V315589.R01.S.doc Version 5.2 Page 15 The medication is stored and administered correctly at the home. It is kept in a locked cabinet in the staff bedroom, which is also locked, there is a fridge should the service users require their medication to kept at a certain temperature, this can also be locked. The home has a policy and procedure on medication. The care staff would benefit from medication update training, to ensure that they are following current practice. 13a Green Lane DS0000035964.V315589.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 22,23 The home has a documented complaints procedure to ensure residents’ views are listened to and acted upon. Systems are in place to ensure residents are safeguarded from abuse and harm. EVIDENCE: The home operates Wigan Social Services Department’s complaints policy and procedure. The home has received one complaint since the last visit. This has been addressed. The complaints procedure is explained in the service agreement. The service users spoken with said that they knew whom to complain to if they were unhappy about anything. The CSCI has not received any complaints about the short break service. The home operates Wigan Social Service Departments Protection of Vulnerable Adults policy and procedure. Some of the staff have attended training in adult protection whilst completing their NVQ level 2 award. The manger said that some staff were having tan update relating to adult protection this month and the remaining staff were receiving training early next year. The care staff spoken with were able to demonstrate how to act as an alerter in terms of adult protection. 13a Green Lane DS0000035964.V315589.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 24,26,27,30 The standard of the environment within the short break service is good providing service users with an attractive and homely place to stay. EVIDENCE: On the day of the visit the premises were safe comfortable, bright, cheerful, airy, clean and free from offensive odours. There is one large lounge with the dining table, a kitchen, a smaller lounge, two bedrooms and two bathroom/shower rooms downstairs. Upstairs there are three bedrooms a staff bedroom and two bathrooms. There are two large garden areas outside and one had two benches and chairs to enable service users to sit out. The home has a planned maintenance and renewal programme for the fabric and decoration of the premises. The last visit by the registered person identified that new furniture should be purchased for the lounge and there is a new carpet in one of the service users bedrooms. There were fresh flowers in vases 13a Green Lane DS0000035964.V315589.R01.S.doc Version 5.2 Page 18 and modern pictures on the walls creating a homely environment and the lounge was tastefully decorated for Christmas with a tree and decorations. The bedrooms all had televisions and hand wash basins. The two bedrooms downstairs have tracking hoists, which can be used by service users who use a wheelchair; usually the service users can choose which bedroom they want to stay in. The furniture and decoration in the rooms was modern. There are locks on the bedroom doors, the service users can have keys if they wish. The bathrooms and shower rooms are suitable for service users’ specialist needs; there is also a shower bed available. The bathrooms and shower rooms are lockable. Water temperatures are monitored in order to reduce the risk of scalding. The utility room has a washing machine and a drier. The washing machine has the specified programming ability to meet disinfection standards. The manager is looking into the option of having a sluice facility. The home currently manages sluicing effectively. On the day of the visit the home was clean and free from malodour. 13a Green Lane DS0000035964.V315589.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 32,33,34,35,36 The recruitment practices are good and appropriate checks are carried out. This ensures that the resident is not put at risk. The staff training provided ensures that the staff are equipped to meet the needs of the service users. EVIDENCE: The rotas indicate that there are sufficient care staff on duty to meet the service users needs. The manager said that staffing levels would be reviewed to meet service users’ changing needs. Of the eleven care staff six have the NVQ level 2, two care staff have almost completed their award. The care staff and the manager were observed interacting in a respectful, friendly and natural manner. The care staff spoken with were able to demonstrate a good understanding of the service users needs. Comment cards received from relatives said “ Staff have always been very helpful” and that it “ seems a very happy atmosphere when I have called.” Also, “ staff are always willing to help you and are welcoming.” The care staff said that they attend staff meetings on a regular basis, the manager confirmed that these take place on a monthly basis and are recorded with actions detailed. 13a Green Lane DS0000035964.V315589.R01.S.doc Version 5.2 Page 20 An examination of a sample of staff records indicated that all staff had two references, enhanced CRB checks, statements of terms and conditions on their personnel file. The application forms are kept separately and could not be viewed. The staff have received training in autism awareness, physical intervention, moving and handling, food safety awareness and specific service user training. Each member of staff did not attend five days paid training and development days per year. The care staff receive regular recorded supervision and have had formal supervision several occasions this year. The care staff also receive an annual appraisal with the manager. The care staff said that the manager calls at the home every day. 13a Green Lane DS0000035964.V315589.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 37,39,42 The record of self-review by the registered provider is infrequent and does not provide the home with adequate quality assurance. EVIDENCE: The manager has been in post seven years and has many years experience of working with adults with a learning disability. The manager has the NVQ level 4 in management. The care staff spoken with said that the manager was supportive and approachable. A comment card said that, “ the manager has done so much for us and is very understanding.” The responsible person has only three recorded visits to the home this year. They should visit once a month and prepare a written on the conduct of the care home each month and these should be made available to the CSCI. The 13a Green Lane DS0000035964.V315589.R01.S.doc Version 5.2 Page 22 home would benefit from a service user survey and this should be published and made available to service users and their representatives. The fire record book demonstrated that emergency lighting, fire bell are tested regularly. There have been many fire drills this year. The home has an accident book that is completed appropriately and a general incident reporting book. There was evidence that health professional had been contacted after an accident. 13a Green Lane DS0000035964.V315589.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 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 3 X 2 X X 3 X 13a Green Lane DS0000035964.V315589.R01.S.doc Version 5.2 Page 24 No 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 YA9 Regulation 13 Requirement Timescale for action 15/01/07 2 YA18 13 3 YA39 26 The registered person must ensure that unnecessary risks to the health and safety of service users are identified and so far as possible eliminated. The registered person must 15/01/07 ensure that arrangements for service users to receive where necessary, treatment, advice and other services from health care professionals is achieved. The registered person must 22/01/07 ensure that they visit the home monthly and prepare a written report on the conduct of the home. 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 YA9 Good Practice Recommendations It is recommended that the risk assessments are expanded and include all risks to the service users and how this is to be minimised. DS0000035964.V315589.R01.S.doc Version 5.2 Page 25 13a Green Lane 2 3 4 YA20 YA35 YA39 It is recommended that the care staff receive refresher training in medication. It is recommended that each member of staff have at least five paid training days and development days (pro rata) per year. It is recommended that there is continuous self monitoring that involves service users; and an internal audit takes place at least annually. 13a Green Lane DS0000035964.V315589.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 13a Green Lane DS0000035964.V315589.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. 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