Inspection on 10/10/05 for 9-10 Jutland Place

This inspection was carried out on 10th October 2005.

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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

9-10 Jutland Place 22/08/07

9-10 Jutland Place 05/04/06

9-10 Jutland Place 12/04/05

9-10 Jutland Place 03/11/04

9-10 Jutland Place 10/05/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Jutland Place (9/10) 9/10 Jutland Place Pooley Green Egham Surrey TW20 8ET Lead Inspector Helen Dickens Announced Inspection 10th October 2005 10:00 Jutland Place (9/10) DS0000013538.V252159.R01.S.doc Version 5.0 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 Jutland Place (9/10) DS0000013538.V252159.R01.S.doc Version 5.0 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. Jutland Place (9/10) DS0000013538.V252159.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Jutland Place (9/10) Address 9/10 Jutland Place Pooley Green Egham Surrey TW20 8ET 01784 436647 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) Royal Mencap (Housing & Support Services) Care Home 8 Category(ies) of Learning disability (7), Learning disability over registration, with number 65 years of age (1) of places Jutland Place (9/10) DS0000013538.V252159.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be: UNDER 65 YEARS OF AGE One named service user who is over the age of 65 years, may be accommodated in the home. 12th April 2005 Date of last inspection Brief Description of the Service: Jutland Place is situated close to Egham town centre, in a residential area. The home is a detached property formed from two semi-detached houses and in keeping with the surrounding area. The home is within walking distance of local amenities. Jutland Place provides accommodation and care for 8 residents, male and female, with learning disabilities, one of whom is over the age of 65. Communal facilities such as the kitchen and conservatory/dining area are on the ground floor and the home has its own private garden to the rear. There is car-parking area to the front of the property. Jutland Place (9/10) DS0000013538.V252159.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over 6 hours and was the second inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. This inspection was carried out by Helen Dickens. Moira Kelly, the manager, represented the establishment. A tour of the premises took place. Four residents, one member of staff and two relatives were interviewed in private as part of the inspection. A number of files, documents and returned ‘comment cards’ were examined as part of the inspection process. This was a positive inspection. The inspector would like to thank the residents, relatives and staff for their time, assistance and hospitality. What the service does well: What has improved since the last inspection? The home continues to improve both managerially and in terms of decoration and maintenance. The new manager continues to up-date documents and policies and review administrative procedures. Three residents bedrooms have Jutland Place (9/10) DS0000013538.V252159.R01.S.doc Version 5.0 Page 6 been decorated and a new shower installed downstairs, this was a requirement from the last inspection. Most of the other requirements and recommendations from the previous inspection have been met. These include additional training for staff, updating and reviewing of care plans in a timely fashion, labelling of items in the fridge and recording what residents take in their packed lunches. Staff levels have also been reviewed to assist with more one-to-one sessions during the week. 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 Jutland Place (9/10) DS0000013538.V252159.R01.S.doc Version 5.0 Page 7 contacting your local CSCI office. Jutland Place (9/10) DS0000013538.V252159.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Jutland Place (9/10) DS0000013538.V252159.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 The statement of purpose and service users guide provides a good overview of the facilities and services offered at the home. However, a more residentfriendly format should be considered in order to assist residents understanding of these documents. New residents would have a full assessment of their needs to ensure the home offers appropriate support and facilities. EVIDENCE: The statement of purpose and service users guide outline the aims, objectives and philosophy of the home, together with services and facilities, and details about the staff. There is a resident-friendly complaints procedure contained within the documents, which would help service users to understand the complaints process. There was a copy of the 2004 Resident’s survey which gave an overview of how existing residents had rated the service. Overall these documents are not in a format suited to this client group and though staff would read the documents to residents to assist them, having a more resident friendly format would better promote the independence of residents. This was highlighted in the last report and will be a recommendation at the end of this report. There have been no new admissions to this home for some time but discussion with the manager makes it clear that residents would only be admitted following a thorough assessment. Trial visits would be available and consideration would be given to staff skills and existing residents. This is also highlighted in the service users guide. Jutland Place (9/10) DS0000013538.V252159.R01.S.doc Version 5.0 Page 10 Jutland Place (9/10) DS0000013538.V252159.R01.S.doc Version 5.0 Page 11 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 and 9 Resident’s can be confident that their care needs are reflected in their care plans and kept under review. A more resident-friendly format would ensure residents have a better understanding of the content of these documents. Residents are supported to take risks as part of an independent lifestyle. EVIDENCE: Care plans examined gave a good overview of residents needs and included input from other professionals as appropriate. Resident’s spoken to confirmed that they were being well looked after and were happy with the care they were receiving. Staff spoken to had good knowledge of individual residents needs. Those care plans examined had been reviewed in a timely fashion by the home. One resident’s annual review by social services was overdue and the manager was asked to chase this up. The care plans are attractive and well organised but not in a format which would be accessible to the residents at this home. The home could better promote resident’s independence by reviewing the format of these documents and encourage more involvement from residents. Appropriate risk assessments were on those residents files examined, and they had been kept under review. Areas covered included mobility, personal care Jutland Place (9/10) DS0000013538.V252159.R01.S.doc Version 5.0 Page 12 and bathing, community activities and transport. Further risk assessments on some activities and issues in the home are highlighted at the end of this report. Jutland Place (9/10) DS0000013538.V252159.R01.S.doc Version 5.0 Page 13 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, and 14. The home encourages and enables residents to take part in fulfilling community activities though some further work needs to be done to ensure all residents benefit. EVIDENCE: Seven of the residents at this home have their own detailed activities plan including adult education, social activities and leisure opportunities. Some have been helping with a very successful gardening project in nearby Laleham, and others do a variety of arts and crafts. On the day of the inspection one resident having an ‘at home’ day was going out clothes shopping with a care worker. Staff rotas have been reorganised to allow one to one support to do whatever they choose, for all residents, one day per week. There was a variety of activity, including examples of residents playing a part in the local community. The mini-bus from the local day centre will be available for use by this home each weekend as soon as staff have successfully completed their mini-bus driving assessment. One resident whose needs have changed is not currently engaged in any activities and there were concerns expressed by the manager and the Jutland Place (9/10) DS0000013538.V252159.R01.S.doc Version 5.0 Page 14 inspector about appropriate mental stimulation for this resident. The manager must review this, taking advice and using suitable volunteers if necessary, to offer more one-to-one support and stimulation to this resident. Standard 14.4 says that long-term residents should have the option of a seven-day holiday per year, included in their fees. However, the home said that this was not available to residents this year. Jutland Place (9/10) DS0000013538.V252159.R01.S.doc Version 5.0 Page 15 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): 20 and 21 The administration of medication at this home is well organised but further work needs to be done to meet this standard in full. Staff training on ageing and death will need to be put in place if residents are to feel confident that all their needs can be met in this regard. EVIDENCE: No residents administer their own medication at this home and therefore staff are responsible for all aspects of the administration of medication. The medicine cabinet was very tidy and administration of medication records complete and up to date. Information about the medicines prescribed for each resident were contained in a folder as a staff resource, and staff who had the responsibility for administering medication were all trained to do so. However, the medicine cupboard keys were not secure and the manager was asked to review this practice. Not all staff who were trained (and already administering medicines) had provided a sample signature at the front of the medicines folder. There were no instructions for some of the medicines prescribed to be given ‘as needed’.and the manager was asked to arrange for this to be in place. The staff typed the medicines administration record and a protocol needs to be in place for double-checking the accuracy of the information copied onto this record, together with any changes which are made. There was no record of the last visit to the home by a pharmacist. The Jutland Place (9/10) DS0000013538.V252159.R01.S.doc Version 5.0 Page 16 manager was asked to follow this up, and arrange for a professional pharmacists advice visit, in order to ensure that current policies and practice are safe and appropriate for the home. The previous two inspection reports required staff training to be arranged on the subject of ageing and death. This has still not been organised and in view of the long delay, the inspector has asked that the manager identify and book training on these subjects within one week and contact CSCI to confirm when this has been done. Jutland Place (9/10) DS0000013538.V252159.R01.S.doc Version 5.0 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 Residents at Jutland Place can be confident that their complaints and concerns will be taken seriously and that they will be protected from abuse. EVIDENCE: The complaints procedure which is in place has been translated into a residentfriendly version, which makes it more accessible to residents. Residents spoken to had no complaints to make to the inspector. Staff were observed to communicate well with residents, assisting them to air their views and opinions. There have been no complaints since the last inspection and the complaints book contained complaints forms as well as acting as a central record for all complaints. Relatives spoken with raised a few minor issues which were passed on to the manager – overall they said they were very pleased with the care their relative received at the home. The staff spoken to were familiar with their responsibilities for protecting vulnerable adults and the home had a copy of the latest Surrey multi-agency procedures for the protection of vulnerable adults. There had been no vulnerable adults issues raised since the last inspection. Jutland Place (9/10) DS0000013538.V252159.R01.S.doc Version 5.0 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): 24,26 and 30 Jutland Place offers a clean and pleasant environment for residents, though a number of maintenance and refurbishment problems currently detract from the otherwise homely atmosphere. EVIDENCE: A number of decorative improvements have been made since the last inspection including redecorating three residents rooms. The premises are generally comfortable, bright, cheerful and airy with suitable light, heat and ventilation. The kitchen is in a bad state of repair and remedying this was a requirement from the previous inspection. The manager said the work was being done in November and contingency plans for provision of food to residents have been made whilst the work is in progress. The inspector asked if the environmental health officer could be asked to visit the home to ensure the new arrangements in the kitchen were safe and suitable. Though there is evidence of maintenance and refurbishment in the home, this should be properly documented with a ‘plan’ for short, medium and longerterm work – this allows for sufficient budgeting. The inspector asked for the Jutland Place (9/10) DS0000013538.V252159.R01.S.doc Version 5.0 Page 19 repair/replacement of the electricity box in the hall, and the decorating of two resident’s bedroom walls, is added to this plan. Bedrooms in this home are very personalised and residents have much or their own furniture. They have chosen colours and furnishings and all those spoken with where happy with their own rooms. There was a concern raised about a resident’s door, which was being left open during the day, whilst the resident was out. Relatives asked if this could be reviewed and this was discussed with the manager. The home was clean and hygienic and completely free from any offensive odours. The manager was asked to review the use of a communal towel in one bathroom and carry out a risk assessment to prevent the spread of infection. The staff should be congratulated on the way they have managed to keep the kitchen exceptionally clean and tidy, despite the outstanding maintenance/replacement difficulties. Jutland Place (9/10) DS0000013538.V252159.R01.S.doc Version 5.0 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): 32,33,35and 36. Residents at Jutland Place benefit by the good attitudes and characteristics of the staff but further specialist training, and a training and development plan, needs to be completed in order to meet these standards in full. EVIDENCE: Staff were observed to be approachable and communicated well with residents. They demonstrated a good level of commitment and motivation, and were comfortable with residents at all times. Staff at this home are all fairly new and they have all completed the induction/foundation training provided by MENCAP. They have also done a number of other courses relevant to their work at the home. Some staff are registered on NVQ courses. The manager is also currently doing the registered managers award. The outstanding requirement from the last two inspections about staff training on ageing and death has been mentioned earlier in the report. Also, a written training plan needs to be drawn up taking into account resident’s assessed and changing needs, and staff requirements highlighted during their supervision sessions. This will allow the home to budget appropriately. Training and development should be linked to the home’s service aims. The home must review its current level of training with regard to 50 of staff having to have NVQ Level 2 or above by the end of 2005. This ratio includes Jutland Place (9/10) DS0000013538.V252159.R01.S.doc Version 5.0 Page 21 agency and bank staff. An action plan needs to be sent to CSCI to show how MENCAP will address this issue at Jutland Place. The manager supervises all members of staff and records on this were well kept. However, one member of staff had not received supervision since March and therefore the frequency of supervision sessions needs to be monitored to make sure all staff get at least 6 formal sessions per year. Staff to resident ratios have been highlighted as an issue in the past and negative comments have been made on a comment card returned prior to this inspection, regarding the number of activities available to residents at the weekend. During the inspection there were times when only the manager was present in the home. Though most residents were out, two of those who remained were unwell. Rotas have been arranged so that each resident has one to one time with a staff member on a weekday when they are ‘at home’. This should be kept under review as it is likely that even fewer activities will then be possible at the weekend if the staff are concentrated on weekdays The manager was asked to review the staff to resident ratios using the Residential Forum matrix, as set out in standard 33.3. Jutland Place (9/10) DS0000013538.V252159.R01.S.doc Version 5.0 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): 37,38 and 42 The residents at Jutland Place benefit from living in a well run home and from a management style which creates an open, positive and inclusive atmosphere. Health and safety are taken seriously at the home but further work needs to be done to meet this standard in full. EVIDENCE: The manager of this home is competent and experienced, and is currently working towards her Registered Managers Award. She is well aware of her responsibilities and demonstrates commitment to the residents and staff. She will need to complete her registration with CSCI as soon as possible and the next steps were discussed during the inspection. There is a very positive atmosphere in the home and the manager, staff and residents were very open to the inspection process. Processes for managing the home were open and transparent and the manager was happy to volunteer information, even if it highlighted some minor fault on the part of the home. Jutland Place (9/10) DS0000013538.V252159.R01.S.doc Version 5.0 Page 23 On the day of the inspection a number of documents were not available for inspection including an electrical wiring safety certificate, records of the last environmental health visit to the home in general, and what steps have been taken to prevent legionella in the home. No policy on dealing with aggressive residents could be found though one resident does have challenging behaviour episodes from time to time. As mentioned earlier, there was no record of an inspection by the community pharmacist. Some risk assessments needed to be drawn up including one for the hot water in the kitchen, and another for infection control relating to a known infection hazard in the home. As mentioned earlier, the electrical box in the hall needs to be repaired or replaced and a risk assessment should be in place until this is done. A risk assessment on the use of members of the community punishment team for gardening needs to be carried out – the manager has verbally checked on the safety issues for vulnerable residents but this should also be documented. Jutland Place (9/10) DS0000013538.V252159.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X 3 X X X 2 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 2 X 2 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Jutland Place (9/10) Score X X 2 2 Standard No 37 38 39 40 41 42 43 Score 2 3 X X X X 2 DS0000013538.V252159.R01.S.doc Version 5.0 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. 1. Standard YA14 Regulation 12(1) 14(2) 16(2)(m) 13(2) Requirement The home must review the opportunities for social and mental stimulation for one resident whose needs have changed. The home must seek professional pharmacists advice and review policies and practices in line with this advice. The manager should seek advice on the matters already highlighted in this report. The requirement that staff should receive training in ageing and death is outstanding from 2 previous reports.(13/12/04) The manager must identify and make bookings for suitable courses as soon as possible. The kitchen refurbishment is outstanding from the previous report, (12/05/05) and the manager must contact CSCI to confirm that the work has started on the planned date The home must review its use of communal towels in the shower/toilet downstairs and carry out a risk assessment with regard to known infection DS0000013538.V252159.R01.S.doc Timescale for action 10/11/05 2. YA20 10/11/05 3. YA21 18(1)(c ) (i) 18/10/05 4. YA24 16(2)(g) 23(2)(b) 11/10/05 5. YA30 13(3) 11/10/05 Jutland Place (9/10) Version 5.0 Page 26 hazards. 6. YA32 18(1)(a) (c )(i) The home must provide an action plan regarding their ability to meet the NMS target of having 50 of care staff being trained to N VQ2 or above by the end of 2005. The above should contain remedial action and dates, and be sent to CSCI. The home should keep under review the ‘staff to resident’ ratio and calculate the numbers of staff required using the Residential Forum matrix. This calculation should be sent to CSCI. The home must devise a written training and development plan for all staff as outlined in the report. The home must carry out risk assessments on the hot water accessible to residents in the kitchen, the broken electrical box in the hall and the use of the community punishment team for the gardening. The home must also make arrangements for the electrical wiring to be inspected, legionella tests to be carried out, and they must take advice from the environmental health officer on the new kitchen. 10/12/05 7. YA33 18(1)(a) 10/12/05 8. YA35 18(1)(a) 10/12/05 9. YA42 13(4)(a) (b)(c) 18/10/05 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. 2. Refer to Standard YA1 YA6 Good Practice Recommendations The home should consider providing the service user guide and statement of purpose in a format more accessible to residents. The home should consider devising a more user friendly DS0000013538.V252159.R01.S.doc Version 5.0 Page 27 Jutland Place (9/10) 3. 4. YA14 YA36 format for residents care plans. MENCAP should reconsider their decision not to allow residents to have an optional funded 7 day holiday this year as recommended in the NMS. The frequency of staff supervision should be kept under review to ensure there are no significant time lapses between supervision sessions, and the 6-8 sessions per year are fairly evenly spread. Jutland Place (9/10) DS0000013538.V252159.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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. 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