Inspection on 04/07/07 for Ashlar House

This inspection was carried out on 4th 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

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

CARE HOMES FOR OLDER PEOPLE Ashlar House St Margarets Hospital The Plain Epping Essex CM16 6TN Lead Inspector Sara Naylor-Wild Key Unannounced Inspection 4th July 2007 10:00 X10015.doc Version 1.40 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 Ashlar House DS0000069327.V345258.R03.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 Older People. 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. Ashlar House DS0000069327.V345258.R03.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashlar House Address St Margarets Hospital The Plain Epping Essex CM16 6TN 01992 570691 01922570692 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) Barchester Healthcare Homes Ltd Miss Emma Bryer Care Home 36 Category(ies) of Dementia - over 65 years of age (36) registration, with number of places Ashlar House DS0000069327.V345258.R03.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Persons of either sex, aged 65 years and over, who require nursing care by reason of Dementia (Not to exceed 36 persons) No more than 25 persons may attend the home on a daily basis in addition to those 36 accommodated. N/A Date of last inspection Brief Description of the Service: Ashlar House is a single storey, purpose built premises, located in the grounds of Sty Margaret’s Hospital. The premises include a number of sitting areas and a dining room with facilities to make hot drinks and snacks. The bedrooms are single with en-suite bathrooms. There are communal gardens that are enclosed and provide seating. The service has provision for 36 places for people with dementia. The service provides nursing care and has close links with the local Mental Health Trust. It is on a main bus route and is a mile from rail and underground services. Epping is close to both the M11 and M25 motorways. Ashlar House is part of the Barchester Care. Fees for residents within Ashlar House are recorded as “beds are contracted to PCT”. This information was received on 05/06/2006. Ashlar House DS0000069327.V345258.R03.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report includes the unannounced inspection site visits on 4th July 2007 and 26th July 2007. The evidence contained in this report was gathered from discussion with managers, staff and relatives, a visit to the home, observation of residents’ interaction, questionnaires completed by residents’ relatives and professionals visiting the home and information provided to the Commission for Social Care Inspection (CSCI). Ms Emma Byers, the Registered Manager assisted the inspector at the second site visit. Feedback on findings was given to her during the visit with the opportunity for discussion or clarification. The inspector would like to thank the Ms Byers, the staff team, residents, relatives and visiting professionals for their help throughout the inspection process. What the service does well: The quality of information gathered about prospective residents is translated into person centred care plans that provide details for staff in how to meet the individuals’ needs. There is a dedicated activities co-ordinator who has an up to date understanding of the way in which social stimulation should be offered to residents with dementia. The staff team are trained to meet the needs of residents and at every level demonstrate a dedication and commitment to continuous development of a quality service that supports residents in a way that enhances their lives. The environment is pleasant and the developments in both the internal and external spaces are designed to give residents the best experience of the building. The manager is enthusiastic and brings innovative thinking to the operation of the home. She listens to the residents, relatives and staff and incorporates their ideas into the planning of the services development. Residents relatives have confidence in the service and statements included “I am confident my relative is looked after”, “I would like to express our sincere thanks and gratitude to all the staff for the love and care they give my relative” “a member of staff has been a pillar of strength to me and has helped Ashlar House DS0000069327.V345258.R03.S.doc Version 5.2 Page 6 my understand my relatives illness” “excellent services, my relative is able to live their life as best as their illness will allow” The catering arrangements seek to understand the individuals’ needs and preferences and deliver a service that meets these with dignity and respect. 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. Ashlar House DS0000069327.V345258.R03.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashlar House DS0000069327.V345258.R03.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents can be confident that the service understands their strengths, needs and aspirations before they move into the home. EVIDENCE: The files of four residents were assessed and these contained the initial assessment of prospective residents needs prior to their moving into the home or the review of existing assessments for established residents. The forms are called the Barchester Total Care Assessment and are made up of a checklist with Y or N responses across the range of daily living issues such as nutrition, mobility and medication. These are supported by a fuller 6 page admission information sheet that provides information about issues such as the individuals medical history, Family connections, registered GP, previous occupation, Religion, legal status, end of life wishes, health, culture, support, Ashlar House DS0000069327.V345258.R03.S.doc Version 5.2 Page 9 mental health and daily living skills. The service uses the Behavioural Assessment Scale of Later Life (BASOLL) assessment as well as specific risk assessments for issues such as falls, mobility, aggression, self-harm, leaving the building. Basoll assessment (Behavioural assessment scale of later life) The assessments seen were completed fully and provided good details needed to determine the suitability of an admission and to support staff in commencing care planning documents. This will support the planned and successful admission of residents and ensure that the service is fully prepared in skills and resources to meet their needs. Ashlar House DS0000069327.V345258.R03.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident that they will be consulted on how their abilities, needs and aspirations are supported, and documented. EVIDENCE: The sample of residents’ plan of care demonstrated that they are made up of individual sheets for each of the outcomes of daily living i.e. eating, continence, and personal care. They are all headed with the issue under consideration, followed by the long-term objective, and then a plan of care written with a description of the individual’s ability and needs. The level of staff support needed is detailed in the final part of the document. These are a very person cantered narrative style that provides positive affirmation of each resident’s abilities. Ashlar House DS0000069327.V345258.R03.S.doc Version 5.2 Page 11 Examples include: X is able to carry out washing and dressing they need prompting and will need some assistance with their back, they choose their own clothes, but needs help to put clothes on in correct order, X likes to be pampered and wear makeup, X enjoys complements on their appearance. The daily records completed by staff report on numbered care plan items and relate therefore to the progress made in meeting the long-term objectives. The health care records in the plans are maintained with entries made by the visiting GP’s or nurses where appropriate. The plans also include a Life story in the form of a short narrative that describes the significant events, relationships family past and present in the residents’ lives. Senior staff have all received training in medication dispensing administer medication. The drugs are kept in a locked temperature controlled room within locked metal cabinets. There is also a fridge with a thermometer to monitor the safe storage of medication. The lockable storage is divided into current medication, stock medication and controlled drugs. The administration of controlled drugs is recorded separately in a controlled drugs log and examination of this determined appropriate records were being maintained. Observation of the administration of lunchtime medication by a senior staff member demonstrated a safe process that adhered to the current guidance. Ashlar House DS0000069327.V345258.R03.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The majority of residents can be assured that they will be provided with a range of activities to suit their preferences. However further development is required to ensure all staff understand how to provide opportunities to residents. EVIDENCE: An activities co-ordinator has recently been appointed to the service but was on leave at time of first site visit. This meant that staff had to provide stimulation as part of the daily routine. In the latter part of the visit staff were seen engaging some residents in games and music was playing. Discussions with the activities co-ordinator during the second visit to the service evidenced that they had a good understanding of the way in which activities should be provided to residents particularly those with dementia. Te co-ordinator spoke about using daily living tasks as opportunities for stimulation and involvement of the residents. They have begun to develop a picture of each resident’s preferences and interests through trial and error of Ashlar House DS0000069327.V345258.R03.S.doc Version 5.2 Page 13 offering the activity. Examples included of going through music tapes with a resident and allowing them to pick the music they liked. The co-ordinator is aiming to draw up a section to add to the care plans that identifies how staff should support resident’s social interests in greater detail. The gardens are being refurbished to provide sensory, vegetable and seaside themes. The gardens are to include areas of raised beds to allow residents to participate in the activity. Funding for this had been raised through a successful application to Government Grants. This required homes to base their application on resident’s choices and the manager had used the feedback in resident’s quality assurance questionnaires as a basis for the project. At the time of the fist visit to the home the dining room was also undergoing refurbishment. The new provision was to include an open plan kitchen area with specially adapted catering equipment for residents to participate in cooking activities and to provide visitors with a means of making refreshments with the residents. The visiting policy is open and welcoming and during the site visits visitors were observed coming and going throughout the day. In some cases relatives support the care of their family member at meal times or in other ways. Comments from relatives included “We as a family are always welcome day or night” The service is working towards Barchester’s “Five Star Dining Award”. This requires the catering staff to work in a customer focused way and includes the quality of ingredients used, the menu choices and range of specialist diets catered for and the presentation of food. The catering manager reported that they were close to attaining recognition for the award. All the staff are involved in the initiative and observations of the mealtime demonstrated that staff ensured that all residents were offered two choices at each meal, and in some cases further alternatives were offered. Resident’s ability to choose was supported by staff offering the two plated meal options as examples. Their choice was the served freshly by the chef from trolley. The Ingredients used are all freshly delivered to the service including vegetables, meat and bread delivered from the local bakery. There is a nutritious balance offered in the menu and residents with difficulty in eating solid meals are offered soft diet and liquidised meals but these are presented in an appetising manner. Ashlar House DS0000069327.V345258.R03.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident that they will be listened to and that their concerns will be actioned. Residents can be assured that they are protected from abuse by the staff’s understanding of safeguarding adults. EVIDENCE: The service has a complaints policy and procedure that is publicised within the home and detailed in the service user guide. A record of complaints received is maintained and details the last recorded complaint as raised in August 2006. The record contains details of the complaint, the investigation into the issue and the outcome of that enquiry with the action taken. There have not been any concerns raised to the Commission since the last inspection. Relatives spoken with and those who responded to questionnaires were aware of the complaints process and were confident that they could raise issues with the manager and that these would be dealt with. Comments included “they have always taken on board my concerns and dealt with them as expected” The service has a Safeguarding adult’s policy and procedure for staff to report allegations of alleged abuse. There is also a whistle blowing policy for staff to raise concerns outside of their immediate line management if necessary. The records held on staff training detailed that the staff had attended a Protection Ashlar House DS0000069327.V345258.R03.S.doc Version 5.2 Page 15 of Vulnerable adults course that will assist them to recognise abuse and understand their responsibilities in reporting this. The staff spoken with during the inspection were able to give an account of the action they would take and demonstrated that they understood the significance of abusive actions. Ashlar House DS0000069327.V345258.R03.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from an environment that meets their needs and provides a homely and welcoming place to live. EVIDENCE: The premises are presented to a good standard with the building maintained to a good state of repair and the environment is clean and free from odours. The service employs a handyman and gardeners. The handyman is diligent and professional in their approach to their role and has ensured that the services compliance with health and safety documentation and staff training in this area is updated. Ashlar House DS0000069327.V345258.R03.S.doc Version 5.2 Page 17 There is a refurbishment programme being carried out with one lounge and communal corridors in centre already completed, the dining room commenced at the first visit had been completed by the second visit to the home and provided an airy spacious room. The new open plan kitchen facility for residents and visitors to access had been fitted with specialist equipment. Including a water boiler and cooker all with built in protection systems to ensure residents do not accidentally turn them on. The gardens are being refurbished to provide a greater stimulation to residents and allow for their participation in horticultural activities. There are enclosed gardens with access from each of the three communal lounges and the dining room. Further work is planned to open the front of the building to incorporate the foyer into the rest of the home. The manager has commissioned local colleges to assist with a design for the foyer that will provide stimulation and added value to the residents using the area. Other considerations were the layout of the front entrance that is being changed to ensure that residents are not confronted by the car park at the end of the corridor. All residents’ rooms were clean and tidy and provided good standard of accommodation. The manager confirmed the opportunity to personalise their rooms was offered to residents where desired. Service users rooms are identified by a memory box, which contains items and written text such as song lyrics that are associated with them. The service has an infection control policy and staff were observed to adhere to the common terms of infection control such as hand washing. There was no noticeable odour in the home. Ashlar House DS0000069327.V345258.R03.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to be cared for by a group of staff that are supported and trained to meet their needs. EVIDENCE: Rotas seen demonstrate that the service maintains a staffing arrangement of four care staff and two nurses on duty for 19 residents. Two housekeeping staff and catering staff support these staff. The observation of staff carrying out their duties during the site visit to the home, demonstrated an unhurried approach to the day with time spent with residents. The only exception to this being the midday mealtime where the numbers did not appear appropriate due to the number of residents requiring assistance. Following the meal the discussions with the staff indicated that of the 19 residents, all but four residents required assistance of some kind to eat their meal. On the day of the first site visit this meant that even with a relative supporting two residents, a number of staff were required to support more than one person to eat the meal at a time. This does not support the dignity of those Ashlar House DS0000069327.V345258.R03.S.doc Version 5.2 Page 19 residents and detracts from the efforts being made by the service in relation to the 5 star catering standards. This was raised with the manager following the visit for further consideration. The manager felt that the temporary rearrangement of the dining room into a smaller space in one of the communal lounges contributed to the issues seen on the day of the visit, but acknowledged that lateral thinking should be applied to the meal time support provided to residents. One relative’s feedback raised concerns about the arrangements for escorting residents to hospital overnight, following a residents lack of escort on a previous occasion until family members could arrive. Residents with dementia cannot be left in unfamiliar environments and where they may have difficulty in communication with people who do not know them. This matter is raised with the service for their consideration of the arrangements for residents with dementia. The sample of three staff records from the 20 employed showed that robust employment checks were undertaken. All the files contained two written references, Criminal Records Bureau (CRB) checks and completed application forms. Applicants had provided proof of their id including birth certificate and two staff who were foreign nationals had proof of work permits. Staff training records is maintained on the services computer for both the individual and an audit of the skills held by the whole staff group. These records identify training staff have undertaken and flags up when refresher courses are due. The manager stated that the main focus of the previous 12 months had been to ensure that all staff obtained necessary health and safety training such as moving and handling, food hygiene, Infection control, although some other topics related to the needs of the resident group had also been provided such as Dementia care and challenging behaviour. The manager recognised the need to build on this basic programme to develop the teams’ skills over the coming 12 months. The service is aiming to have 100 of care staff with NVQ level 2 or above in the coming year. Currently there are over 10 staff with NVQ level 2 or 3 and a further 6 staff undertaking courses. In addition the housekeeping staff are applying to do NVQ in housekeeping. The current staff group benefit from several staff who are cascade trainers including a senior staff who provides dementia training, two staff are Moving and handling cascade trainers and Two staff are trained fire marshalls. Staff spoken with welcomed the opportunities for training and one person said that the work they do and the skills they have learnt has opened their eyes to the needs of older people with dementia. Ashlar House DS0000069327.V345258.R03.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and stakeholders can be assured that a competent manager who listens to their views. They can be confident that they will be consulted, but cannot be assured that their views are progressed. EVIDENCE: The manager has been in post for nearly 12 months at the time of the inspection. They have extensive experience and skills in both managing services and the provision of specialist dementia care. These skills are evident in the successful collaboration of the staff team approach to meeting the needs of residents that is continuing to improve at each inspection. Ashlar House DS0000069327.V345258.R03.S.doc Version 5.2 Page 21 The service has a quality assurance system with survey sent to relatives and professionals as well as an adapted resident’s questionnaire centred on topics such as the food and activities on offer. Staff assist residents to complete these short questionnaires with pictures, and answers testify an honest approach in doing so. The manager states that the questionnaires were developed in response to a requirement made in previous inspection to have a more appropriate survey form for residents, and that the issues raised in them in relation to the garden facilities were the basis of the grant application made for funding the refurbishment of the areas. Quality assurance systems are intended to gain information anonymously in order to understand the difference between expected and actual performance of the services processes to identify opportunities for improvement. It is not the aim to deal with individual issues. Discussions took place between the manager and the inspector in relation to other methods that could be used so that staff are not directly involved in gaining responses from residents. The responses received form relatives and professional’s surveys are audited and a bar chart report of the collated evidence is provided. The document does not however provide evidence of how the conclusions are to be addressed by the service and the manager reported that the outcomes are not published. The manager was able to identify methods for informing relatives and others through the regular newsletter the service publishes. Staff supervision is carried out by senior staff who have undertaken training in supervision. The programme of supervision is maintained on the computer system and demonstrates that staff receive one to one sessions with their supervisor at frequent intervals. The record of discussion is held by the supervisee with a tick list of topics signed off by both parties retained by the service. Staff spoken with said they gained from the opportunity to have these sessions and recognised how they contributed to their overall performance. Ashlar House DS0000069327.V345258.R03.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 Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 3 X 3 Ashlar House DS0000069327.V345258.R03.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO 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 OP33 Good Practice Recommendations Residents, relatives and other stakeholders should be able too understand how their feedback given through quality assurance questionnaires has been incorporated into the services development plans. Further developments should be considered in how residents are consulted about the quality of the service. In particular those residents without speech or who require assistance to make their views known. A member of the staff team should not carry this out. 2. OP33 Ashlar House DS0000069327.V345258.R03.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Ashlar House DS0000069327.V345258.R03.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. 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