Inspection on 10/10/06 for 261 Passage Road

This inspection was carried out on 10th October 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

261 Passage Road 12/09/07

261 Passage Road 26/02/06

261 Passage Road 13/09/05

261 Passage Road 01/02/05

261 Passage Road 13/07/04

261 Passage Road 13/03/04

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 18-65 261 Passage Road Brentry Bristol BS10 7JA Lead Inspector Karen Walker Key Unannounced Inspection 10th October 2006 09:30 261 Passage Road DS0000026544.V310585.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 261 Passage Road DS0000026544.V310585.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. 261 Passage Road DS0000026544.V310585.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 261 Passage Road Address Brentry Bristol BS10 7JA 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) 0117 9593223 0117 9699000 www.brandontrust.org The Brandon Trust Mrs Susan Alexandra Massey Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 261 Passage Road DS0000026544.V310585.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate 1 named person under the age of 40 with physical disabilities until that person leaves the home then the registration reverts May accommodate persons aged from 40 years upwards Date of last inspection 26th February 2006 Brief Description of the Service: 261 Passage Road is operated by the Brandon Trust to provide residential care for up to five residents all of whom are currently female with a learning disability, aged 40 years and over. The home is registered with the Commission for Social Care Inspection. The manager is Mrs Susan Massey who has a wealth of experience supporting residents with learning disabilities and with the current resident group. She is a qualified Learning Disability nurse as is the Deputy Manager, Joyce Montague. This home blends in well with its neighbouring properties and is close to many local community facilities. There is the shopping area of Crow Lane within walking distance; Henleaze and Westbury village are a short car or bus ride away. The home has access to major bus routes and is a short ride away from the Mall Shopping precinct and the facilities it has to offer. The home has the added benefit of a large wellmaintained garden that is accessible to all residents. The garden provides a safe environment in that it is well fenced off and the home is not on a main road. 261 Passage Road DS0000026544.V310585.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and covered all of the key standards. The opportunity was taken to talk with residents and staff and to view records in respect of them. Two residents were case tracked and discussions took place with them and their key-worker. Positive comments were received from residents including’ “I like it here, staff listen to me and if I was unhappy they would do something”. Residents also had the opportunity to complete the CSCI feedback forms. These forms further evidence that the staff team are very aware of individuals’ needs and preferences. The pre-inspection questionnaire was completed prior to inspection and information taken from it. Records relating to the management of the home were examined and the requirements set at the last inspection were reviewed. Fees vary according to assessed need and residents are expected to pay for any extras i.e. hairdressing, clothes, holidays. What the service does well: Residents benefit from a friendly motivated staff team who are knowledgeable of the needs of the resident group. Residents can feel assured that they will be cared for through to the end of their lives with the relevant support bought in from other professionals where necessary. Staff members made a number of comments relating to the service and some include, “we couldn’t have wished for a better team”. “Residents don’t fit into our regimes, we fit into theirs”. Residents comments were positive and included; “ I like it here I like my keyworker”. “I can make a complaint and can talk to my key-worker and the manager”. Residents are planning a holiday so that refurbishment works can be carried out on the kitchen and living areas. Residents will also benefit from a wet room in the downstairs bathroom. 261 Passage Road DS0000026544.V310585.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. 261 Passage Road DS0000026544.V310585.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 261 Passage Road DS0000026544.V310585.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,5 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Residents have the information they need to enable them to make an informed choice regarding service provider. Residents can feel confident that they are made aware of the terms and conditions of occupancy and that their individual needs will be met. EVIDENCE: One of the residents confirmed that she had seen her contract and had been given a ‘places to live agreement’. The agreement is user friendly with both pictures and the written word included. It is recommended however that a picture of the resident and their room be included to ensure it is personalised. Records show and residents confirmed that an assessment of need took place prior to the resident moving into the home, one resident said, “I have been here a while now and I have seen my social worker, we had a meeting to decide if I like it here”. Staff members confirmed that they were aware of the needs of the resident group and were able to demonstrate how they meet assessed needs. 261 Passage Road DS0000026544.V310585.R01.S.doc Version 5.2 Page 9 The service user guide and statement of purpose is up to date and contains all relevant information relating to service provision and the home. One of the residents has the benefit of an advocate and has supported her to compile a ‘wish list’ for a new placement. The social worker will be reassessing this persons needs with a view to finding a new placement. 261 Passage Road DS0000026544.V310585.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 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 is good. This judgment has been made using available evidence including a visit to the service. Residents are able to make informed decisions about aspects of their own care and the running of the home. Residents are supported to take risks and risk assessments link with the care plans in place. EVIDENCE: The staff members on duty were knowledgeable of the needs and preferences of the resident group and showed a commitment to meeting assessed needs. Residents were asked how they are supported to make everyday choices and one said ‘I am asked about all sorts of things and make a lot of choices, staff help me’. She also confirmed she knew of her assessed needs and associated risk assessments and was able to name some of the documents in place. 261 Passage Road DS0000026544.V310585.R01.S.doc Version 5.2 Page 11 There are appropriate risk assessments in place for those residents that may become abusive or aggressive and discussions took place around this area of support. It is recommended that an ABC chart (Antecedent, Behaviour Consequence) be put in place to identify any triggers leading up to the behaviour displayed and what happened as a result. The deputy manager and a member of staff on duty at the time of inspection were able to demonstrate how the team had offered ‘choices’ to residents with limited communication skills. Photographs were taken of the home and added to the statement of purpose and service user guide. Residents meetings now take place more frequently although the deputy manager said it is hard sometimes to get everybody involved. Ways were discussed in how to engage people at different times of the day. ‘My personal plans’ are in place and these detail the likes and dislikes essentials and preferable for each individual. Work is being done on these documents to ensure they are person centred and include achievable targets, including who will do what and when in order to reach a goal set. 261 Passage Road DS0000026544.V310585.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 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 is good. This judgment has been made using available evidence including a visit to the service. Residents have the opportunity to take part in appropriate activities and are supported to access the local and wider community. Their rights are respected and relationships are supported and maintained. Residents are offered a healthy diet and are able to contribute to the menu. EVIDENCE: It was evidenced that there are many opportunities for personal development. One new resident said ‘I am getting to know the residents and staff better and staff help me do the things I want to do’. The statement of purpose highlights the need to ‘support people and enable them to live the life they choose’. Staff confirm this ethos and gave positive examples of the support they provide to individuals. 261 Passage Road DS0000026544.V310585.R01.S.doc Version 5.2 Page 13 One resident said, “I have been to see lots of shows and Im going to see Beauty and the beast and Cats. Discussions were held with this resident and her key-worker with regards making and maintaining friendships. It was suggested that the News-2-you Brandon Trust newsletter could be used to seek a friend for evenings out and social activities. Records evidence a wide range of community facilities are accessed including shopping centres, pubs, healthcare faculties, cinema, theatre etc. Staff records show that training courses have been accessed in order to facilitate positive communication. One staff member was able to accurately describe one of the new residents communication needs and how best to support her to ensure they are met. The deputy manager said that all of the residents have the opportunity to lock their bedroom doors but chose not to. Residents are supported to vote and the deputy manager gave an example of supporting a resident with little knowledge of political affairs and the importance of not influencing her decision. Residents confirmed they were able to visit friends and relatives and staff were very helpful with the provision of transport. Staff support residents to use the community by providing transport in the form of staff cars, a motobility car and public transport. Family members are welcomed into the home at any reasonable time and join in with celebrations where possible. Menus detail varied and balanced meals and residents confirmed they could choose what they eat and are offered alternatives to the day’s menu. The team are building up a ‘menu folder’, which contains large pictures of various foods and drinks to support residents with little or no verbal communication with informed choices. This is good practice. 261 Passage Road DS0000026544.V310585.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20,21 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Residents are supported in a way that suits them. Their healthcare needs are adequately assessed and met. Medication practices are sound although residents will benefit from individual PRN protocols to ensure staff are fully aware of when and how often they can administer PRN medication. The aging, illness and death of a resident is handled with respect and as the individual would wish. Family members are supported throughout the whole process. EVIDENCE: The opportunity was taken to examine the medication administration sheets. 261 Passage Road DS0000026544.V310585.R01.S.doc Version 5.2 Page 15 It was noted that one resident was written up for Diazepam on an ‘as and when’ (PRN) basis. This was discussed with the manager at the last inspection and it was agreed that a protocol must be put in place to ensure staff are aware of any triggers to the behaviour that may challenge, when they can administer and how often. This has not yet been put in place although the manager has compiled a list, this is not adequate and the requirement stands. It was agreed with the deputy manager to extend the timescale. The home has a walk in shower facility to meet the needs of those residents who are growing older and whose mobility needs are changing. The home has a stair lift in place to enable residents’ easy access to personal bedrooms. Its use has now been risk assessed. Records show that additional specialist support is accessed where necessary, this includes input from the physiotherapist, speech therapist and occupational therapist. One new resident confirmed she had been registered with the general practitioner and had undergone a new patient check. She said “I’ve had my eyes tested and I’m seeing someone about a new shower seat and a hoist to help me get in the bath if I want to”. Staff members said that individuals are supported to choose and buy their own clothes and visit the hairdressers, two residents confirmed this. It was noted that the residents’ appearance reflects their personalities. The home are to be commended on their care of termally ill residents and the support given to not only the resident in question but to the other residents, each other and the family members. The deputy confirmed that she still keeps in touch with family members of residents that have passed away especially at significant times of the year. One staff member has attended bereavement counselling so she can support one resident in particular to deal with the loss of a family member. She is being supported to make an entry into the ‘book of remembrance’ and contribute to the ‘tree of light’ managed by St Peters Hospice. The resident said she also has a memory box. 261 Passage Road DS0000026544.V310585.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 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 is good. This judgment has been made using available evidence including a visit to the service. Residents can feel confidant that they will be protected from abuse and that their concerns will be listened to and acted upon. EVIDENCE: Training records show and two staff members confirmed that they attended Adult Protection training this year. Staff are aware of the Protection policies in place including whistle blowing and the DOH ‘No Secrets’ in Bristol guidance. There are no protection issues in this home. The complaints book was examined and the Service Development Manager (SDM) appropriately followed up one complaint. The complaints book now takes the following format: Date, nature of complaint, action taken and timescale, outcome and signature. It was seen that the complaints procedure was available in the service user guide this includes details of how to contact the CSCI. How to make a complaint was also detailed on the notice board in the kitchen. The staff member spoken with said the staff team and residents were supported to complain. 261 Passage Road DS0000026544.V310585.R01.S.doc Version 5.2 Page 17 A staff member spoken with at the last inspection told the inspector that a member of the staff team attends a monthly ‘communication’ meeting. These meetings are used as a forum to discuss concerns, managerial and organisational issues. 261 Passage Road DS0000026544.V310585.R01.S.doc Version 5.2 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 is good. This judgment has been made using available evidence including a visit to the service. Residents live in a comfortable, safe and homely environment that is clean and tidy. EVIDENCE: Residents will be going on holiday in November 2006 to enable refurbishment of the kitchen and redecoration of the lounge area. The downstairs bathroom will become a ‘wet room’ to ensure accessibility to those who needs are changing. Residents confirmed they liked the home and their own bedroom space. One resident was happy to show the inspector her new bedroom. She said ‘ I love it all my things can go in it, its nice’. All of the bedrooms have sinks and the appropriate furniture necessary to ensure comfort and the meeting of individual needs and lifestyles. 261 Passage Road DS0000026544.V310585.R01.S.doc Version 5.2 Page 19 Residents chose not to hold keys and lock their bedroom doors and the manager said she would continue to offer this choice through resident meetings. When residents become ill and require extra support with equipment this is sought appropriately and includes pressure relieving mattresses, commodes and chairs. 261 Passage Road DS0000026544.V310585.R01.S.doc Version 5.2 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 is good. This judgment has been made using available evidence including a visit to the service. A motivated, competent and effective staff team who are appropriately supervised supports residents. Residents are protected by the organisations recruitment policies. EVIDENCE: Staff confirm they have clearly defined job descriptions and are aware of their roles and responsibilities within the home. Staff are aware of the General Social Care Council Code Of Conduct and have all received their own copies. They are also aware of their own skill limitations and one staff member said, ‘if I didn’t know I would ask’. 261 Passage Road DS0000026544.V310585.R01.S.doc Version 5.2 Page 21 Training records show a varied choice of training courses are offered. Staff confirm they have learnt a lot about palliative care through experience and instruction from the district nurses. Other courses accessed are: Counselling awareness NVQ standardisation Performance management Ethnic minority groups Protection of vulnerable Adults Loss and bereavement Mental health and learning disabilities One staff member said, ‘ I enjoy attending training’. The deputy manager is a part of the ‘ethnic and minority group’ that meet regularly and offer support to other staff members who need support or advice regarding racial issues. They have links with the Support Against Racial Incidents (SARI) group who offer professional advice and support. It was noted that a complaint was made regarding a racial incident within the home this was addressed and dealt with in a positive way with support from the Brandon Trust. The Brandon Trust ensures residents are protected by a robust recruitment policy. All staffing records relating to recruitment including Criminal Record Bureau checks are held at the Trust HQ. Staff members confirmed that the manager is able to view the records and ensures she checks references etc prior to employment. 261 Passage Road DS0000026544.V310585.R01.S.doc Version 5.2 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 is adequate. This judgment has been made using available evidence including a visit to the service. EVIDENCE: Fire records were examined and it was noted that fire training and fire drills were not taking place at times prescribed by the Avon Fire Brigade. Discussions took place with the deputy manager who was reminded that the staff must undertake training and drills at least every 6 months. The deputy manager said that weekly fire alarm checks take place and these checks include carbon monoxide testing. The fire logbook confirmed this. The stair lift is serviced annually and was last done in December 2005. The inspector saw a number of policies and procedures put in place by the organisation and staff are expected to sign up to these policies. 261 Passage Road DS0000026544.V310585.R01.S.doc Version 5.2 Page 23 There was a specific policy for ‘service user involvement’ that was in an accessible style and encouraged resident involvement in service user forums. There was a bullying and harassment policy; whistle blowing and other staff related policies as well as generic policies and procedures needed to comply with current legislation. An emergency and crisis policy has been put in place June 2004. The Brandon Trust is a large organisation with overall responsibility for the home. There is a business plan in place that is produced annually; this then feeds into the homes annual plan. Quality assurance issues were discussed and it is recommended that feedback on service provision be sought from relatives and other people who have contact with the home. The feedback should include not only a checklist but also a space for people to have a say on what the home does well and what the home could improve upon. This can then be used to inform the annual plan and improve service provision. Monthly regulation 26 visits take place carried out by the service development manager. The liability insurance document was displayed along with the registration certificate. There are clear lines of accountability throughout the Trust that the staff are aware of. 261 Passage Road DS0000026544.V310585.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 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 3 33 X 34 3 35 X 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 2 4 3 X 3 X X 2 X 261 Passage Road DS0000026544.V310585.R01.S.doc Version 5.2 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 YA20 Regulation 13(2) Requirement Individual protocols must be put in place to ensure staff are aware of when and how to administer PRN medication. SECOND REQUIREMENT Staff must undertake training and drills at least every 6 months. Timescale for action 31/10/06 2 YA42 13(2) 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. 1 YA5 Add a picture of each resident to the ‘places to live agreement’ and include pictures of their room etc. This will ensure the document is personalised and relates to individuals. ABC chart (Antecedent, Behaviour Consequence) to be put in place to identify any triggers leading up to the behaviour displayed and what happened as a result. 2 YA9 261 Passage Road DS0000026544.V310585.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 261 Passage Road DS0000026544.V310585.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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