Inspection on 10/07/07 for 28 Pasley Street

This inspection was carried out on 10th July 2007.

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

Other inspections for this house

28 Pasley Street 23/08/06

28 Pasley Street 28/09/05

28 Pasley Street 20/04/05

28 Pasley Street 04/11/04

28 Pasley Street 29/04/04

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 28 Pasley Street Stoke Plymouth Devon PL2 1DP Lead Inspector Brendan Hannon Unannounced Inspection 10th July 2007 9:45 28 Pasley Street DS0000003507.V340686.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 28 Pasley Street DS0000003507.V340686.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. 28 Pasley Street DS0000003507.V340686.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 28 Pasley Street Address Stoke Plymouth Devon PL2 1DP 01752 561459 01752 561459 headoffice@durnford.org 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) The Durnford Society Limited Ms Michelle Durrant Care Home 10 Category(ies) of Learning disability (10), Learning disability over registration, with number 65 years of age (10) of places 28 Pasley Street DS0000003507.V340686.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users may be between the ages of 18 and 65 years of age. Also service users may be over the age of 65. The home may accommodate a maximum of 10 service users at any one time. Service users may be male or female. 23/08/06 Date of last inspection Brief Description of the Service: The home is located in two combined terraced houses, on the end of a terraced street, in the Stoke area of central Plymouth. A full range of amenities and facilities are within walking distance though, the home has its own vehicle. The home can accommodate up to ten people over three floors. The home is in an unusual layout being entered on the ground level at the front but then with stairs both descending to accommodation in the lower ground floor level and ascending to accommodation on the first floor level. There is one bedroom on the ground floor. There are three communal bathrooms and three communal showers. There are no shared rooms and due to the age of the building all the ceilings are reasonably high giving an additional feeling of space in the home. There are two communal lounges, a kitchen diner and another dining area off one of the communal lounges. There is a large area of patios and parking space to the rear of the building. This can be accessed either from the lane to the rear of the building or from the rear of the lower ground floor. The service offered by the home is for men and women with a learning disability over the age of 18 and perhaps beyond the age of 65. The home would have difficulty supporting people with significant mobility difficulties. The people that presently use the service have a mixed range of ages and abilities. The fees charged by the home range from £650 to £1160 per week. 28 Pasley Street DS0000003507.V340686.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. Preparation for the inspection included analysis of the Annual Quality Assurance Assessment supplied by the CSCI, the last inspection report, and contacts with the home over the last 12 months. An inspection plan was developed from this information. The inspector was in the home from 9.45am to 4.30pm on the 10/07/07, and met with the Deputy Manager. He also met with the General Manager with responsibility for the home at the organisation’s head office on the 11/07/07 to inspect some personnel and quality assurance documentation. Overall he was with the providers of the service for eight hours. The following methods were used during the inspection. The care of three people that use the service was tracked during the inspection. The inspector spent time with all of the people that use the service on the 10/07/07. The Deputy Manager, and the two other staff members present were spoken with on the 10/07/07. Three staff personnel and training files were sampled during the inspection. The inspector toured the building. The relatives or friends of all seven people that use the service were sent a survey questionnaire by post and four surveys were returned which were all positive towards the service. An opinion on the service was sought from Plymouth Social Services the commissioning local authority for the majority of the people using the service, and their response was positive. All areas of documentation in the home were inspected to evidence compliance with the National Minimum Standards. Documents inspected included assessments of peoples’ needs and their care plans, various records including medication administration records, staff/employment records, and health and safety records. All the information gathered during the inspection was considered in the writing of this report. What the service does well: The house is comfortable, cosy and very clean. There is plenty of good food. People have enough things to do to be happy. Each person can have their bedroom as they want it. There are always enough staff to help and people get all the help they need. The staff are safe to be with. If you want to live there the staff will tell you about what it is like. The staff are good at helping people to move in and be happy. 28 Pasley Street DS0000003507.V340686.R01.S.doc Version 5.2 Page 6 The staff know how to help people and the staff do their best. If a person has a problem it is easy to get help. The staff make sure that if someone is sick they will get help from a doctor. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 28 Pasley Street DS0000003507.V340686.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 28 Pasley Street DS0000003507.V340686.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides enough information to allow a person that is considering using the service to make an informed decision with help from their supporters. Peoples’ admission to the service has been handled sensitively in the past. EVIDENCE: Both the Service Users Guide and the homes Statement Of Purpose were available. People that use the service have their own copy of the Service Users Guide. This information enables people considering using the service and their supporters to understand the service provided. The service has decided over the next few months to develop the Service User Guide into new communication formats including video, audio, symbols and Braille so that information about the home is more accessible to people who are considering using the service. There is presently enough information provided by the service to allow a person, with the help of their supporters, to make an informed choice whether or not to use the service. There has been no admission to the home since the last inspection on 23rd August 2006. However previously the service has successfully supported people to move into the service. Records showed good evidence that peoples needs are met by the service. 28 Pasley Street DS0000003507.V340686.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Good quality care is being delivered. However the assessments of peoples’ needs, their care planning and their individual risk assessments should be improved so that the people using the service receive more thoroughly planned care. EVIDENCE: The care of three people was tracked during the inspection. The assessments of these peoples needs, and the care plans to meet these needs, were in place and were sampled as part of the inspection. Each of these people had an assessment and care plan that was adequate. However the assessment of some peoples’ emotional and psychological needs was out of date and the subsequent planning of care to meet these needs was not comprehensive. The planning of peoples’ social and leisure needs was also limited. Progress has been made in this area since the last inspection but there continues to be some work to do to bring assessment and care planning up to a good standard. The service has introduced a programme of Person Centred Planning (PCP) in addition to care planning but this is at an early stage of development. The 28 Pasley Street DS0000003507.V340686.R01.S.doc Version 5.2 Page 10 planning of peoples’ personal development goals is only noted inside the PCP document. The goal sections of the PCP documents sampled were blank. There was an adequate individual risk assessment for each person, which identified most of the risks affecting them. There are some agreed restrictions in place of normal freedom of choice and access to facilities. However some of these are not explained in either people’s care planning or individual risk assessments. An example is when people do not use their bedroom door keys either by choice or because of risk. Such restrictions of choice or facilities were discussed and are in place either to reduce risk to an acceptable level, or because the person has chosen not to use an available facility. However thorough care planning and risk assessments help the service to assess that the need for people to be safe has been balanced against their right to normal freedoms. There was considerable evidence of the home actively seeking to empower the people that live there to have a more involved and independent lifestyle. Examples of this included the use of bedroom door keys, a photo board to indicate which staff were on and would be coming on duty, a photo board to allow people to show when they are in or out of the building, and the use of laminated pictures of different meals to help people make informed meal choices. Further evidence of the peoples’ active lifestyles was available in the peoples’ individual daily diaries. People, who are supported to participate in their home, and are empowered, have more control over their daily lives. 28 Pasley Street DS0000003507.V340686.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people that use this service have enough appropriate, fulfilling activities to ensure a good quality of life. People have enough varied, good food. EVIDENCE: Evidence about people’s individual lifestyles came from the Annual Quality Assurance Assessment, ‘residents’ daily diaries, and information from the staff on duty. Community activity engaged in by people who live at the home includes work placements, church services, local and city centre shopping, using the local pub, swimming, trips to the theatre, walking, music therapy classes, using a social club, and visiting friends. Peoples’ activity is also supported within the home including doing cooking, shopping and cleaning to develop their skills, sewing, DVD films, music, singing and dancing, hand massage and nail painting. An accurate record of peoples’ activity and experience of the service was contained in the ‘residents’ daily diaries. This information helps the review of care planning and risk assessment. 28 Pasley Street DS0000003507.V340686.R01.S.doc Version 5.2 Page 12 It could be seen from the menu plans, food delivery records and the various stocks of food and drink in the large fridge freezer, that residents are supplied with enough, good quality food. A record of the food provided is in place and shows that the people that use the service are being provided with a healthy and varied diet. The menu plan for the week is devised with consideration for peoples’ food preferences and following discussion with them. This discussion is supported with the use of pictures of the meals available. A main weekly household shopping is done at a supermarket by a group of the people that use the service with the support of staff. People are asked if they want to participate in this shopping. People that use this service receive enough varied, good food and they also participate in the choice, purchase, and as appropriate preparation, of their food. 28 Pasley Street DS0000003507.V340686.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The personal care needs of people that use the service are met. People are well supported to access health services. The administration of peoples’ medication is managed adequately by the home. EVIDENCE: The inspector spent time with all the people that live at the service and there was no observable evidence of any personal care issue not being met. The delivery of personal care is covered within each persons care planning. A sample of peoples’ records and care planning showed regular contact with various health services including psychiatric health services, learning disability nursing, local GPs, chiropodists, opticians and dental health services. All the people that use the service have a new health action plan in place. The Durnford Society Ltd. has redesigned this document in a total communication format using symbols and simplified language. The health of people that use the service is well supported. The home uses a monitored dosage system for medication administration. Medication administration records were seen and were mostly well maintained. However the administration of some cream/ointments had not been well 28 Pasley Street DS0000003507.V340686.R01.S.doc Version 5.2 Page 14 recorded which led to staff not being able to track when skin conditions suffered by people that use the service had worsened. There was an accurate list of the medication received by each person in their care planning and in their health action plans. Peoples’ health is maintained by adequately managed and administered medication. 28 Pasley Street DS0000003507.V340686.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The welfare of people that use the service is protected by thorough adult protection and complaints procedures. EVIDENCE: There is a complaints procedure leaflet, which has been developed to help communication using WIDGET symbols and simplified English. This was displayed on the notice board by the front door. This leaflet is also attached to each person’s individualised Service Users Guide. There has been one complaint made to the home during the past twelve months concerning noise levels heard outside the home. This issue has been addressed and the complaint has ended. The home has appropriate anti abuse policies and procedures in place. The staff have received anti abuse training both through the Learning Disability Award Framework (LDAF) induction training and through specific anti abuse training. People that use the service can be assured that the management and staff are working to keep them safe. 28 Pasley Street DS0000003507.V340686.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27,28,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people that use the service benefit from a homely, comfortable, clean and well-maintained building. EVIDENCE: The home was toured during the inspection and no significant repairs were noted. The quality of the living environment and the standard of decoration in the home were very good. The home was very clean, hygienic and odour free. This unannounced inspection found the bathrooms, toilets, kitchen and laundry exceptionally clean and well maintained. Appropriate laundry facilities are in place to control the spread of infection. Staff were seen regularly washing their hands. Standard 30 has been exceeded and the service is commended for cleanliness and hygiene within the home. The majority of the people that use the service are now over 45 years of age. As a result the service has made physical adaptations to the facilities to meet peoples increasing physical needs. For example a new bedroom with ensuite 28 Pasley Street DS0000003507.V340686.R01.S.doc Version 5.2 Page 17 shower and WC has been developed on the ground floor. Physically adapted bathrooms and toilets are present throughout the building. However all the bedrooms, except the new bedroom on the ground floor, are only accessible from the ground floor by stairs, either down to the lower ground floor, or up to the first floor. The service has been careful to ensure that it can always meet the physical needs of all the people that use the building. All the bathrooms and toilets are fitted with override type locks that can be locked from the inside to give people privacy but that can also be opened from the outside in the event of an emergency. The bathrooms have been decorated to make them feel more domestic in character. The bedrooms have been decorated and personalised to the taste of the people using them. All the bedrooms are fitted with appropriate key operated locks. Some people choose to use these locks and others do not. The organisation has provided the resources to maintain the décor in the home to a high standard. Furnishings and fittings are of good quality. Peoples’ needs are met by their appropriate and good quality living environment. 28 Pasley Street DS0000003507.V340686.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Enough, competent, safe and trained staff are available to meet the needs of people that use the service. EVIDENCE: Staff personnel records were sampled and inspected for recruitment, training and staff supervision. These records showed that recruitment procedures to protect vulnerable adults are carried out effectively. All staff had had appropriate Protection of Vulnerable Adult (POVA) register and Criminal Records Bureau (CRB) checks. These checks help to ensure that the people that use the service are kept safe. It was noted at the last inspection carried out in August 2006 that staff turnover was high. Staff turnover has fallen. The Annual Quality Assurance Assessment showed that the home has had approximately 40 staff turnover in the past year. The Deputy Manager in charge was confident that staff turnover would continue to fall. The Deputy Manager in charge stated that the staffing level is adequate to meet the needs of the people that use the service. The rota record showed that there are often three staff on duty during the day including managers. The 28 Pasley Street DS0000003507.V340686.R01.S.doc Version 5.2 Page 19 daytime minimum staffing level is two staff at all times. There are two staff on duty between 4.00pm and 11.00pm, when night staffing begins. At night there is one waking staff and one sleeping in staff on duty. Often there are additional staff on duty during the day to support people to undertake specific activities. The Deputy Manager in charge said that the staffing level in the home is adequate to meet the needs of the people that use the service at this time. A thorough training programme is run by the organisation to ensure that the level of qualification of the staff is maintained. At present 53 of the care staff are qualified to NVQ2 in Care, or above. The organisation is also actively training new staff within the induction programme and existing staff in the Learning Disability Award Framework (LDAF), which is designed to give care staff specific skills to work with people with a learning disability. This training enables all staff to meet the needs of the people that use the service. Basic necessary training and additional training was also checked and was comprehensive. This level of training demonstrates that the organisation provides a trained competent work force that is safe and can meet peoples’ needs. The staff members receive individual supervision from the homes two managers. The staff are being regularly supervised though not at the frequency stated in the organisations policy. The staff are being adequately supervised to meet the needs of the people that use the service. 28 Pasley Street DS0000003507.V340686.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home is effective, ensuring that peoples’ needs continue to be met. EVIDENCE: The Registered Manager, Michelle Durrant, came into post at the beginning of April 2005. She has both the Registered Managers Award and the NVQ4 in Care, qualifications. The management and staff were seen to be working well together. Good working relationships promotes good quality support for the people that use the service. The organisation has redeveloped the Quality Assurance system. A quality assurance process will be carried out every year. There is a separate Quality Assurance process for staff and this was last carried out in February 2007. The outcomes of this process were almost all very good. 28 Pasley Street DS0000003507.V340686.R01.S.doc Version 5.2 Page 21 A Quality assurance process is being carried out for people that use the service, their relatives, and professionals. Student nurses from the local community learning disability team have in person gathered the views of the people that use the service. This process will report its outcomes soon. The service has made significant efforts to gather information objectively and so produce meaningful feedback on the service from those who use, or are in contact with it. The service and organisation are commended for the efforts they have made on this issue. Regulation 26 monthly reports for the home have been received sporadically by the CSCI from the organisation. The last report was received for a visit carried out in January 2007. The organisational management for the home is advised that the CSCI should receive these reports regularly. The records seen during the inspection were generally good, such as the accident record, and residents’ daily diaries. These records assist management in monitoring the delivery of support to people that live at the home. 28 Pasley Street DS0000003507.V340686.R01.S.doc Version 5.2 Page 22 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 3 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 3 26 X 27 3 28 3 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 4 3 X 3 X 28 Pasley Street DS0000003507.V340686.R01.S.doc Version 5.2 Page 23 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 YA6 Good Practice Recommendations All the people using the service should have a care plan which is comprehensive and detailed. All the peoples’ needs should be identified and how staff are to meet these needs. Each person should have comprehensive and detailed individual risk assessments. These assessments should include all restrictions of choice or personal freedom agreed to be in the person’s best interests. All prescribed medications being administered by the home should be signed for comprehensively. 2. YA9 3. YA20 28 Pasley Street DS0000003507.V340686.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 28 Pasley Street DS0000003507.V340686.R01.S.doc Version 5.2 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!