Inspection on 31/07/06 for 17 Berryfield Road

This inspection was carried out on 31st July 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

17 Berryfield Road 19/06/08

17 Berryfield Road 18/01/06

17 Berryfield Road 08/09/05

17 Berryfield Road 21/02/05

17 Berryfield Road 12/10/04

17 Berryfield Road 16/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Berryfield Road (17) 17 Berryfield Road Bradford On Avon Wiltshire BA15 1SU Lead Inspector Mrs Jacqui Burvill Unannounced Inspection 31st July 2006 09:00 Berryfield Road (17) DS0000028388.V292279.R01.S.doc Version 5.1 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 Berryfield Road (17) DS0000028388.V292279.R01.S.doc Version 5.1 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. Berryfield Road (17) DS0000028388.V292279.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Berryfield Road (17) Address 17 Berryfield Road Bradford On Avon Wiltshire BA15 1SU 01225 864397 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) Ordinary Life Project Association Bernadette Anne Saunders Care Home 4 Category(ies) of Learning disability (3), Learning disability over registration, with number 65 years of age (1) of places Berryfield Road (17) DS0000028388.V292279.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: The home is run by the Ordinary Life Project Association (OLPA). 17 Berryfield Road is a domestic style, semi-detached property in a residential area of Bradford on Avon. It is next door to another OLPA care home, which is at no. 19. There are some local facilities and a bus service nearby. The town centre offers a wider range of shops and amenities. The home has its own people carrier for trips out. Each service user has their own room on the first floor. There is a communal lounge with a dining area. The service users receive support and personal care from a permanent staff team that is managed by Bernie Saunders. The fees range from £686 per week. Inspection reports are available in the home. There is one vacancy in the home. Berryfield Road (17) DS0000028388.V292279.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit for this inspection took place on 31st July. The inspector met with and spoke to three staff in total as well as the manager. There was a tour of the premises. Care plans, risk assessments, menus, medication, health and safety documents, some policies and procedures and staff training records were looked at. There was a second pre – arranged visit on the 4th August to meet with service users, who were out at various activities on the 31st July. The inspector also met with two relatives. Pre inspection information had been obtained and this included information about service users and staff working in the home. A site visit was made to the OLPA head office on 16th May 2006 to check on staff recruitment records. Surveys were sent to three service users and their relatives. All of the surveys were returned. One relative’s comment was that the service user ‘has been made to feel welcome by the friendly and caring staff and has settled in happily. We are very pleased with the progress and well satisfied with her new home.’ What the service does well: Service users benefit from a caring and comfortable home, with staff who support and promote choices, so that service users can live a fulfilling life. There are clear guidance documents and risk assessments regarding particular care needs that are required in the home. These are clearly described and easy to follow. These documents have provided good underpinning of knowledge and practice for staff to follow and this has had a positive impact on the lives of service users. Daily diaries are well recorded, showing clearly and objectively what service users have taken part in on any particular day. Risk assessments for service users are in place and have been regularly reviewed. The staff team are fully involved in this process and this ensures a consistent approach, which has had positive outcomes for service users. Berryfield Road (17) DS0000028388.V292279.R01.S.doc Version 5.1 Page 6 Service users take part in active social lives, which include attending day care centres, colleges and clubs, as well as other community based events and venues. The way in which service users receive support from other healthcare professionals is well documented. This shows how staff have followed up on actions they have needed to take and what effect this has had on the service user. Service users have been supported in accessing the complaints procedure as they have a stamped addressed postcard with the CSCI contact details on it. What has improved since the last inspection? What they could do better: One service user enjoys a particular activity at the weekends. Staff support this with the family, yet this good practice has not been reflected in the care plan. A total of four recommendations have been carried forward since the last inspection. Staff have completed medication training within the organisation, but this has not involved an external provider as recommended at the last inspection. The manager has attempted to find a local pharmacist who would be able to provide this to no avail. One recommendation from the last inspection was that the organisation devises a policy and procedure about gender issues that may arise when providing personal care. The registered manager has devised guidance about this within the home for staff to follow, but the organisation has yet to devise a more formal approach. It was a recommendation from the last inspection that the manager attends an external adult protection training course. This has not happened yet. Berryfield Road (17) DS0000028388.V292279.R01.S.doc Version 5.1 Page 7 The manager has not been able to complete a recommendation yet that she is involved in the interviewing of staff, as no staff have been recruited since the last inspection. 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. Berryfield Road (17) DS0000028388.V292279.R01.S.doc Version 5.1 Page 8 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 Berryfield Road (17) DS0000028388.V292279.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 This standard was not assessed as no new service users have been admitted since the last inspection. EVIDENCE: Berryfield Road (17) DS0000028388.V292279.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users benefit from a care plan that reflects their needs, choices and management of risks. EVIDENCE: Service users each have their own care plan and a Shared Action Plan, which describes their own goals and objectives. The manager explained that the shared action plans are in the process of being set up. Two are in progress, but were not able to be seen. Meeting dates have been set to arrange this. Last year’s shared action plans were seen as evidence of goals being set and met. All three care plans were looked at. Each one has a checklist so that keyworkers can review them monthly. This is above the level set by the National Minimum Standards and is good practice. In one case, the plan had Berryfield Road (17) DS0000028388.V292279.R01.S.doc Version 5.1 Page 11 not been reviewed since March 2006, plans were generally reviewed on a monthly basis. Service users plans were detailed about their needs and how they were to be met. There were signposts in the care plans to other documents that provided additional guidance about a particular care need. There was evidence of good practice in this area as the manager had researched the care need and made positive connections with other relevant organisations. For one service user, attending church and having family contact was especially important. This had not been reflected in the care plan and this was discussed with the manager. Service users are involved in making decisions about their lives and the daily record and shared action plan shows some of the choices that service users have made and how they are supported to make decisions. This includes trips out and choices over activities in the home and meals. Risk assessments are in place and these are regularly reviewed. One set of risks for one service user were reviewed on a recent staff team day, so all of the staff were included in the elements of risk taking. This approach supports service users with consistency. There is a second risk assessment file with more detail about specific conditions relevant to service users and guidance for staff to follow in managing this. Berryfield Road (17) DS0000028388.V292279.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users take part in and benefit from a range of activities and relationships within their community. Service users are supported to eat healthily and enjoy their meals and mealtimes. EVIDENCE: On the first day of inspection, all of the service users were involved with activities in the community. One service user receives support from the staff team when taking part in activities in the community, whilst other service users are taken to the activities, but remain there with staff who work there. Berryfield Road (17) DS0000028388.V292279.R01.S.doc Version 5.1 Page 13 Service users attend local colleges and day care centres at least four days a week, as well as a club one evening a week. On the second visit, staff and service users were observed talking to each other about the day and what the service user had done. Service users asked staff questions about various things and staff replied in a caring and courteous manner, which reassured them. Staff and service users spoke about various trips they had been on recently and showed the inspector some photos. Service users’ diaries show that they have active and enjoyable social lives. Entries are clear and objective and describe the choices service users have made. Some service users have one to one staff support on outings and one involved a recent coach trip to Minehead. Service users have also had a holiday this year in Bognor Regis. Further holidays are planned with a day care group and at the OLPA caravan later this year. Each plan has a section on how service users take part in household tasks and routines, and this is recorded further in the daily diary. There are menu plans set out in the kitchen for staff and service users to follow. Service users are actively involved in the shopping and preparation of meals. Special diets or guidelines are in place and relevant to the care needs of service users and are easy for staff to follow. Each service users’ diary has a section for staff to fill in describing what service users had to eat for lunch and evening meal that particular day. Berryfield Road (17) DS0000028388.V292279.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users receive personal care and support in the way that meets their needs. Service users benefit from the way staff follow up and act on the best way to meet service users’ physical and emotional needs. Service users are not able to manage their own medication, but are supported in managing their medication by the staff team. EVIDENCE: Each care plan describes how service users’ receive support with their personal care. This includes details about how service users like to have their medication administered. There was good evidence showing how service users have received support from other health care professionals. This included actions that staff had taken Berryfield Road (17) DS0000028388.V292279.R01.S.doc Version 5.1 Page 15 in following up appointments, or outcomes for service users when they had been discharged. There is a section in the care plan about service users receiving personal care from staff with different genders. It was a recommendation from the last two inspections that the organisation devise a policy and procedure about this. Each service user now has a statement in their care plan, which says that service users have agreed and are happy to receive personal care from staff with a different gender. There is a description of how the manager would cope with the situation should a service user say they were not happy to receive personal care. This is dated and signed by the manager and service user. The organisation has not devised a policy and procedure on this yet, as recommended by the CSCI. Medication records were looked at for all of the service users. These were all in order, with records to show what medication had been administered, received and disposed of. Staff have received drug administration training within the organisation. The policy and procedure states that only staff who have received drug administration training can administer medication and all staff have done so. There was a previous recommendation that drug administration training includes guidance and involvement from an outside professional. This was discussed with the manager. She was able to provide evidence of contact with a local pharmacist, who had been unable to provide any training. Guidance available from the CSCI was shared with the manager and this describes aspects of training and how it can be met. Berryfield Road (17) DS0000028388.V292279.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users views are sought and staff listen and act on these. Service users are protected from abuse, neglect and self harm by a range of policies and procedures. EVIDENCE: There have been no complaints since the last inspection. The organisation has devised a range of policies and procedures about how to manage different types of complaints. This describes the procedure for logging complaints and shows the way complaints can to be referred to senior management, should the complainant not be satisfied with the response. Service users have a stamped addressed postcard to the CSCI in their bedrooms, for them to use if they need to. The registered manager explained that possibly only one service user really understands this process. All service users are asked in their monthly ‘tenant’ meetings if they are happy or have anything they would like to complain about. There is guidance in the home about adult protection, which is linked to the Wiltshire and Swindon ‘No Secrets guidance. One member of staff interviewed accurately described the process used to make a referral to the adult protection team. Berryfield Road (17) DS0000028388.V292279.R01.S.doc Version 5.1 Page 17 There have been no referrals to the adult protection team. It was a recommendation that the manager attends an external adult protection training course. This has not happened yet. There are separate descriptions of how service users receive financial support within the home and how their affairs will be managed. There are additional policies and procedures on whistle blowing, bullying and harassment. Berryfield Road (17) DS0000028388.V292279.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users live in a safe, clean and comfortable home. EVIDENCE: 17 Berryfield Road is in a quiet residential area in Bradford on Avon. The home fits in with the local environment. The sitting and dining rooms are currently being re-decorated by care staff and service users are being involved in choosing the colours and décor. There is a kitchen, downstairs cloakroom, and a garage that has been converted into a utility room. There is a staff office and sleep in room on the ground floor. On the first floor, there are four bedrooms; each service user has their own bedroom, which also has a hand washbasin. Berryfield Road (17) DS0000028388.V292279.R01.S.doc Version 5.1 Page 19 Bedrooms are individually decorated and reflect service users’ tastes and interests. One service user has their own key to their bedroom and is responsible for this. There is a large garden with a patio area that has garden furniture. The manager described plans to add more plants and rejuvenate the garden. The home was clean, tidy and smelled fresh on the day of inspection. Berryfield Road (17) DS0000028388.V292279.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area was adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users benefit from staff knowledge and awareness of their needs. Service users are supported and protected by the organisation’s recruitment polices and procedures. EVIDENCE: Staff have received training in the following areas provided by the organisation since the last inspection; adult protection, drug administration and fire safety training. External training courses attended have included palliative care and training about a particular syndrome. The registered manager has provided cascade training after the latter event. Two staff have not had adult protection training and two other staff have not had training in a particular condition relevant to the needs of service users. Two staff out of six have a National Vocational Qualification at level 2. A further two staff are registered to start their NVQ level 2 and one staff member is going to start the Learning Disability Award Framework, which provides underpinning knowledge for an NVQ level 2. Berryfield Road (17) DS0000028388.V292279.R01.S.doc Version 5.1 Page 21 A visit to the OLPA head office took place on 16th May 2006. This was to discuss staff records and advise the organisation about changes to way staff records can be held. As a result, the organisation plans to implement this in due course. All staff recruitment records were in order. Berryfield Road (17) DS0000028388.V292279.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users benefit from a well run home, where their safety and welfare is promoted. Service users are contributing to a review of quality in the home and would benefit from a clearer structure about the process. EVIDENCE: The registered manager has completed NVQ level 4 and has managed this service for over two years. The registered manager has recently been registered to manage another care home within OLPA. Staff reported how management arrangements were working well. Berryfield Road (17) DS0000028388.V292279.R01.S.doc Version 5.1 Page 23 The manager described how she works a least four sleep in duties per month, two in each house. Team meetings are held separately. She commented on the excellent support she has received from the two teams and how this has enabled some flexibility of staffing. The organisation have some quality assurance policies and procedures, which describe the following: the Annual General Meeting, service users questionnaires, tenants meetings, managers and team meetings, Regulation 26 visits, external inspections and the cross referencing of standards. The organisation has started to devise a system for gathering the views of service users, relatives and stakeholders. Managers have been asked to send questionnaires out so that information about these views on the quality of the service can be assessed. The form includes a section for comments and for people to think about one thing the organisation could do better. The quality assurance policy and procedure comments on the range of ways that quality had been assessed and this included Regulation 26 visits and other methods. The policy and procedure needs to be amended to reflect this process. This should include the aims of the questionnaire and how the organisation plans to implement any changes that may be suggested. During the first site visit of the home, the fire alarm was tested as part of the routine checks. A fault developed as it was being tested. The manager dealt with this promptly and an engineer was called to the home and the fault was fixed within a very short time. The fire records were checked and all of these were in order. There are good health and safety checks in the home and there are separate files for environmental risk assessments and checks on the temperature of hot water. Berryfield Road (17) DS0000028388.V292279.R01.S.doc Version 5.1 Page 24 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 N/A 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Berryfield Road (17) DS0000028388.V292279.R01.S.doc Version 5.1 Page 25 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 YA39 Regulation 24 Requirement The Commission is supplied with a report of the most recent review re: quality assurance that has been carried out in accordance with Regulation 24 of the Care Homes Regulations 2001. COMMENT: The organisation has devised a questionnaire, which is being sent out to stakeholders, relatives and service users. Carried forward from the last inspection, due to be met by 30/04/06 Timescale for action 31/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA18 Good Practice Recommendations That OLPA develop a comprehensive organisational policy on gender and personal care, which will reflect good practice and the range of factors that need to be taken DS0000028388.V292279.R01.S.doc Version 5.1 Page 26 Berryfield Road (17) into account (outstanding from last inspection). COMMENT: Carried forward. This has been met in part, as the registered manager has devised a statement on each service users’ care plan about this. 2. YA20 That an appropriate outside professional, e.g. a pharmacist, contributes to the training that staff receive in medication procedures and drug usage (outstanding from last inspection). COMMENT: Carried forward from the last inspection. The manager has made contact with a pharmacist who was unable to provide training. That the manager attends an external course in the protection of vulnerable adults procedure. COMMENT: Carried forward from the last inspection, as this has not been met. That the registered manager is involved in the formal interviews for new members of staff. COMMENT: Carried forward from the last inspection, as no new staff have been recruited. Service users’ spiritual needs and family contact should be described in their care plan. 3. YA23 4. YA37 5. YA6 Berryfield Road (17) DS0000028388.V292279.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Berryfield Road (17) DS0000028388.V292279.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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