Inspection on 18/07/06 for Evergreen

This inspection was carried out on 18th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Evergreen 15/02/06

Evergreen 08/05/05

Evergreen 02/11/04

Evergreen 14/06/04

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

CARE HOME ADULTS 18-65 Evergreen Cottage Place Bye Lane Copthorne West Sussex RH10 3LF Lead Inspector Mrs M McCourt Unannounced Inspection 18th July 2006 08.40a Evergreen DS0000057956.V290997.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 Evergreen DS0000057956.V290997.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. Evergreen DS0000057956.V290997.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Evergreen Address Cottage Place Bye Lane Copthorne West Sussex RH10 3LF 01342 719111 01342 719111 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) Independent Lifestyles Limited Mrs Donna Wellman Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Evergreen DS0000057956.V290997.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th February 2006 Brief Description of the Service: Evergreen is a care home registered to accommodate up to two Service Users between the ages of eighteen and sixty-five years with learning disabilities. The registered provider is Independent Lifestyles Limited for whom Miss Donna Hawes is the responsible individual, and the Registered Manager is Ms Donna Wellman. The current scale of monthly charge is £1,647.58. This information was provided by the Registered Manager. Additional charges are made for personal items, such as; personal shopping, toiletries, hairdressing, clothing and so on. The home is in Copthorne between the towns of Crawley and East Grinstead both of which have train stations, shops and other amenities. It is a detached, single storey building and the accommodation includes two single bedrooms and a spacious lounge/dining area. There are extensive grounds that can be easily accessed by the residents. The Service Users Guide and Statement of Purpose can be located at the home, and are accessible to Service Users, staff, relatives and anyone else interested in the service. Evergreen DS0000057956.V290997.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection was undertaken by one Inspector on Tuesday 18th July 2006 and lasted a total of six hours. Pre-inspection planning took approximately two days. A full tour of the building took place and included the observation of Health and Safety matters, hygiene issues, decorative order and a general overview of the atmosphere created within the home. Two staff members and the Registered Manager were spoken to at the time of inspection. Case tracking was carried out by examination of relevant records and information held on the staff and residents. The Inspector also spoke with both of the Service Users accommodated at the home. Policies and procedures were examined during the site visit. What the service does well: What has improved since the last inspection? The previous inspection highlighted a need for a better quality assurance system. Since that time the home has developed a questionnaire that is sent to staff, relatives, Service Users and care providers, from which results are collated and a document published. A quality audit and assessment is in place and was carried out in March 2006, looking at a range of issues important to the home. Evergreen DS0000057956.V290997.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Evergreen DS0000057956.V290997.R01.S.doc Version 5.1 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 Evergreen DS0000057956.V290997.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5. The outcome for Service Users was found to be adequate. Prospective Service Users individual needs are assessed prior to admission. A Statement of Purpose is available to Service Users, visitors and any interested parties all times. The home should ensure a signed contract between the home and the Service User is in place, detailing breach of contract. EVIDENCE: A Statement of Purpose and Service Users Guide are available and are kept in the office. The Service Users Guide is written using the Widget programme, making it more accessible for Service Users. Assessments are in place from the placing authorities. The Inspector looked at both of the assessments, and found that neither have been signed or dated and also did not highlight a follow up date. From the assessments, the home has developed a good, comprehensive plan of care for each of the Service Users. Goal plans are in place detailing specific aims or help with certain tasks Evergreen DS0000057956.V290997.R01.S.doc Version 5.1 Page 9 using a step-by-step process for staff to follow. Care reviews are held on an annual basis. Risk assessments are in place and include; medication, inappropriate behaviour, mobility, choking and so on. These have not been signed by either the Service User or a representative. Contracts are in place on individual files, but both were not dated, with the contract details page for one Service User being completely blank. Both had been signed by Service Users, but the Registered Manager admitted that one of the Service Users was not capable of understanding a contract. Neither of the contracts detailed a care plan or what would constitute a breach in contract by either party. Evergreen DS0000057956.V290997.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 and 9. The outcome for Service Users was found to be adequate. Service Users would benefit from more frequent care reviews in order to continuously assess changing needs and requirements. Details of local advocacy services should be made available to Service Users. The home supports Service Users to take responsible risks within the scope of their disabilities. EVIDENCE: It is difficult for the home to fully involve Service Users in drawing up their care plans because of their level of understanding, but families, relatives and advocacy services could be used to help with the process. Both Service Users have a wide range of health issues, and therefore the home is required to involve specialist care for them. Communication was seen from Evergreen DS0000057956.V290997.R01.S.doc Version 5.1 Page 11 Speech Language Therapy, Pressure Sore Advisory, Physiotherapy, Psychiatry and so on. Care plans are reviewed annually. The Inspector suggested, especially given the various health issues that these be reviewed more regularly, at least every six months. The home does not have details of local advocacy services, although the manager said she would contact the Martyn Long Centre if she needed to. The Inspector suggested that she obtain information on local groups. The Inspector observed that Service Users are supported to make choices about their lives. One of the Service Users told the Inspector that she was going out to attend a drama class and that she really enjoys it. She also said that her favourite colour is yellow and on looking around her bedroom it was noted that it was decorated in yellow and pink. The home does have a written procedure of unexplained absences and completed missing persons forms were in place on individual files. Evergreen DS0000057956.V290997.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 and 17. The outcome for Service Users was found to be good. Service Users are supported to access a range of activities and are encouraged to regularly visit local community facilities and events. Service Users are supported with a healthy diet, which includes special dietary advice for one of the Service Users. EVIDENCE: Both Service Users attend day centres on a part-time basis throughout the week. One of the Service Users spoken with said that she was going to do drama, which she really enjoys. In addition she also attends yoga and Look Good/Feel Good, and is due to start cookery classes in September. Service Users take regular trips out into the community; shops, supermarket, restaurants, cinema, leisure centre, horse-riding and so on. One of the Service Evergreen DS0000057956.V290997.R01.S.doc Version 5.1 Page 13 Users owns a rabbit which she takes pleasure in looking after. She told the Inspector that she likes stroking and holding him. In-house entertainment includes music therapy and aromatherapy. One of the Service Users does hold her own front door key. Staff were observed knocking before entering a Service Users bedroom and there is also a sign on the door reminding staff to knock, and the consequences if they do not! One of the Service Users needs to follow a special diet due to a health condition. There is plenty of literature in the kitchen to remind staff about it. In addition a meal planner is on display and a log is kept of all meals eaten. Evergreen DS0000057956.V290997.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 and 20. The outcome for Service Users was found to be adequate. Service Users must be supported to access specialist health care where required. Reviews should be held more often due to the complex needs of the Service Users. Medication policies and procedures are in need of review and improvement. EVIDENCE: A flexible regime for getting up was observed. On the day of inspection one of the Service Users was enjoying a lie-in. Records of health appointments are in place, and include dental, physiotherapy, psychiatry, cardiology and so on. A diary system is used for booking and planning future health appointments and the home records assessments carried out for specific health issues. Evergreen DS0000057956.V290997.R01.S.doc Version 5.1 Page 15 Health plans have been sent to individual Service Users and should have been completed by their G.P. practices. However, the plans for both Service Users are still blank. The Inspector asked why this was the case and the Registered Manager said that she finds the surgery uncooperative at times. Some months ago, a psychiatrist requested blood tests for one of the Service Users and these were booked with the practice nurse. However, on the morning of the tests the surgery rang and said that they were cancelling the tests and where refusing to do them because of the behaviour that the Service User can at times display, despite the fact that she had been particularly calm that morning. Approximately two weeks later the Service User concerned experienced a seizure which she did not recover from, and was therefore taken to hospital where further tests were carried out. It was discovered that the Service Users’ Tegretol levels were too high and her medication was then adjusted. The Inspector was of the opinion that the Registered Manager must ensure that Service Users receive where necessary, relevant treatment and advice from health care professionals, and whilst the surgery were continuing to keep the Service User registered with them, they had a duty of care and must be challenged on this issue. The registered provider must ensure that appropriate steps are taken to ensure this situation is prevented in the future and a requirement has been made in respect of this. The home does carry out a care review and the Care Manager holds a care plan review meeting, each on an annual basis. The Inspector was concerned that the reviews should be held more often due to the complex needs of the Service Users. Monitoring and reviewing of specific health conditions does take place, with detailed records being held on individual files. However, some of the information held is duplicated and therefore files could be streamlined somewhat. Medication is stored in a lockable cupboard. The home uses the Boots MDS system and holds a contract with them. Their last pharmacy check was in December 2005. Examination of MAR sheets found that staff are regularly signing for medication administered. However, a running total of quantities is not carried forward onto the MAR sheet, and quantities supplied are not being entered. Storage of medication found that rectal diazepam was not being stored below 22 c. Open bottles of Lactulose were not dated. On checking a bottle of PRN diazepam, records suggested that there should have been 22 tablets available, Evergreen DS0000057956.V290997.R01.S.doc Version 5.1 Page 16 but there were only 10. Co-dydramol tablets – records showed there should have been 50, but there were only 37 present. The registered provider must ensure that appropriate steps are taken to remedy this situation and a requirement has been made in respect of this. The home’s medication policy states that two staff must administer medication at all times. However, this is not always possible in a small home. Often there is only one staff member available. The policy was reviewed in April 06 and according to the Registered Manager, should have been changed at that time. Evergreen DS0000057956.V290997.R01.S.doc Version 5.1 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. The outcome for Service Users was found to be good. Service Users are protected from abuse, neglect and unnecessary self-harm. EVIDENCE: The Commission has not received any complaints in respect of this service. The complaints policy and procedure were both available and are up-to-date. A complaints log book is available and there have been no complaints logged to date. The complaints procedure is in picture format and was seen displayed on one of the Service User’s bedroom walls. Records examined during the inspection demonstrated that all staff had received training in recognising signs of abuse and further discussions confirmed that they were fully aware of how to report any concerns. One staff member spoken with demonstrated that she was aware of neglect, medication, lack of choice, physical and emotional abuse issues and would call the police if she felt it necessary. The West Sussex County Council Adult Protection procedures were available at the home. Evergreen DS0000057956.V290997.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, 25, 26, 27, 28 and 30. The outcome for Service Users was found to be good. Service Users live in a homely, comfortable and safe environment. It is nicely decorated throughout and is well maintained. The home would benefit from an on-going renewal and redecoration plan. EVIDENCE: The Inspector conducted a tour of the building. The home consists of a one storey, detached bungalow, which includes two bedrooms, kitchen, lounge/diner, office, bathroom, toilet and utility room. The property is situated on a good size plot of land that makes up the garden, and is set back from other properties, giving it a secluded feel. On the day of inspection the home was clean, tidy and nicely decorated throughout. Furniture, fixtures and fittings were all of a good standard and well maintained. There is a book to log any maintenance issues in, but no onEvergreen DS0000057956.V290997.R01.S.doc Version 5.1 Page 19 going renewal plan was available for inspection. The renewal plan needs to be provided in more depth. Service Users’ bedrooms have been personalised to suit individual taste. Service Users share a bathroom and a separate toilet. The Inspector noted that the shower hose in the bathroom was broken. Evergreen DS0000057956.V290997.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): 31, 32, 34, 35 and 36. The outcome for Service Users was found to be good. Service Users are supported and protected by the home’s recruitment policy and practices. Service Users are supported by a competent and qualified staff team. EVIDENCE: The staffing rota shows that the home employs two staff on an early shift, two staff on a late shift with a sleep in person covering nights. This usually provides a 1-to-1 ratio each day. The Inspector looked at two staff files. Job descriptions are in place. Out of eight staff, three hold NVQ’s and one person is due to commence theirs. Of the files sampled, recruitment procedures show that staff have receive CRB checks, two written references, signed contracts, in-house induction, and application forms. A three month probation period is provided for new employees, although there had not been an acknowledgment of this on one of Evergreen DS0000057956.V290997.R01.S.doc Version 5.1 Page 21 the files looked at, the other file was for a new employee, and therefore did not contain a completed probation record. Monthly staff meetings are held and cover subjects such as; Service Users, Adult Abuse procedures, CSCI inspections, training, medication and so on. The Inspector spoke with one permanent member of staff and a bank worker. They were able to demonstrate their awareness of Adult Protection issues and confirmed that they do receive supervision regularly, every eight weeks, although there were no supervision contracts available. The Registered Manager told the Inspector that annual appraisals are held. The permanent member of staff spoken with said that she is offered training and is able to request it whenever she feels it necessary. Individual training records are available, but there is no training and development plan. The Registered Manager said that there is currently no forward planning done with regards to training, instead, individual staff needs are identified within supervision. The Inspector was of the opinion that the manager looks at the various health needs of the Service Users and identifies relevant training to suit their future requirements. The Registered Manager said that a comprehensive and thorough in-house induction is completed when staff members start, from this they commence the LADAF training prior to NVQ. Evergreen DS0000057956.V290997.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, 41 and 42. The outcome for Service Users was found to be adequate. Recorded accidents should be reviewed on a regular basis in order to detect any familiar patterns, and from this observation, risk assessments updated regularly. The home must comply with fire regulations. EVIDENCE: The Registered Manager is Donna Wellman, who has seven years experience of working with people with a learning disability and has managerial experience of two years. Ms Wellman is working to obtain NVQ level 4 and intends to complete the RMA after she has finished her NVQ studies. Following the last inspection a quality assurance survey has been implemented. A questionnaire is sent to staff, relatives, Service Users and Evergreen DS0000057956.V290997.R01.S.doc Version 5.1 Page 23 care providers, from which results are collated and a document published. A quality audit and assessment is in place and was carried out in March 2006. The Registered Manager said that it should be carried out annually from now on. It covers management, staffing, service provided, Service Users, day care, finances and record keeping. Records kept at the home are in good order, tidy and have been reviewed in April 2006. The Inspector was of the opinion that there is a duplication of information, and it would benefit the home if some of the files were streamlined. There is evidence of H & S monitoring, although on examination of the accident file, there were many falls recorded for one particular Service User and on discussion with the Registered Manager the Inspector suggested that a reviewing procedure be implemented in order to identify similar accidents. These can then be followed up by risk assessments to inform staff how better to work with individuals to reduce the falls, or any other accidents highlighted by the accident forms. The fire file showed that regular testing of equipment, lighting and alarms is in place. A service contract is available with B-9 Fire and they last visited in September 2005. However, drills are not carried out on a regular basis. There have only been four recorded since early 2004, and the Inspector is of the opinion that this is below what is required by the fire regulations. In addition there is one risk assessment in place, but not dated and another one dated March 2001 with no review date on it. Despite advice from the fire service in 2003, electric sockets are still over loaded. The Inspector suggested that this risk be reduced immediately by re-arranging the electric plugs. There are many notices in the kitchen regarding food hygiene, handwashing, fridge/freezer temperatures and so on, although the fridge temperature regularly runs above the recommendation, sometimes at 8 c and 9 c with no action taken. All food within the fridge was covered and dated, but opened jars/bottles of ketchup, brown sauce and salad cream had not been dated on opening. Evergreen DS0000057956.V290997.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 3 2 3 3 x 4 x 5 2 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 3 26 3 27 3 28 3 29 x 30 3 STAFFING Standard No Score 31 3 32 3 33 x 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 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 2 2 x 3 x 3 x 2 2 x Evergreen DS0000057956.V290997.R01.S.doc Version 5.1 Page 25 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. Standard Regulation 13 (1) Requirement The registered person shall make arrangements for Service Users (a) to be registered with a general practitioner of their choice and (b) to receive where necessary, treatment, advice and other services from any health care professional. (On going timescale) The registered person shall make suitable arrangements for the recording, handling, safekeeping and safe administration and disposal of medicines received into the care home. Timescale for action 30/09/06 30/09/06 YA19 2 YA20 13 (2) 30/09/06 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 YA5 Good Practice Recommendations The registered manager develops and agrees with each prospective Service User a written and costed DS0000057956.V290997.R01.S.doc Version 5.1 Page 26 Evergreen 2. YA6 3 4 YA7 YA41 4 YA42 contract/statement of terms and conditions between the home and the Service User. 5.2 (v) rights and responsibilities of both parties and who is liable if there is a breach of contract. 6.6 – The Plan is drawn up with the involvement of the Service User together with family, friends and/or advocate as appropriate, and relevant agencies/specialists. 6.10 – The Plan is reviewed with the Service User (involving significant professionals, and family, friends and advocates as agreed with the Service User) at the request of the Service User or at least every six months and updated to reflect changing needs and agreed changes are recorded and actioned. 7.3 – Staff help Service Users, if they wish, to find and participate in local independent advocacy/self-advocacy groups. 41.3 – Individual records and home records ar secure, up to date and in good order and are constructed, maintained and used in accordance with the Data Protection Act 1998 and other statutory requirements. 42.2 – The Registered Manager ensures safe working practices including: (iv) food hygiene – correct storage and preparation of food to avoid food poisoning. 42.6 – The Registered Manager ensures that risk assessments are carried out for all safe working practice topics covered in Standards 42.2 and 42.3, and that significant findings of the risk assessments are recorded. Evergreen DS0000057956.V290997.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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 Evergreen DS0000057956.V290997.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. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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