CARE HOME ADULTS 18-65
Ashley/Phoenix Unit RNID Poolemead Centre Watery Lane Twerton Bath Bath & N E Somerset BA2 1RN Lead Inspector
David Smith Unannounced Inspection 2nd February 2006 09.30 Ashley/Phoenix Unit DS0000040650.V276698.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ashley/Phoenix Unit DS0000040650.V276698.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ashley/Phoenix Unit DS0000040650.V276698.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Ashley/Phoenix Unit Address 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) RNID Poolemead Centre Watery Lane Twerton Bath Bath & N E Somerset BA2 1RN 01225 332818 01225 480825 RNID Mrs Julie Kim Sheppard Care Home 11 Category(ies) of Sensory impairment (11) registration, with number of places Ashley/Phoenix Unit DS0000040650.V276698.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. May accommodate up to 11 persons aged 18 to 64, requiring personal care. 5th September 2005 Date of last inspection Brief Description of the Service: Ashley/ Phoenix Units are situated on the first floor of the central Poolemead building and provides support and care for adults with a single or dual sensory loss, and associated learning disabilities. The building is divided into two distinct areas, Ashely and Phoenix, with 11 bedrooms in total. Each separate area has a lounge, kitchen and dining space. There is no structural barrier between the areas, but each provides for a specific group of service users and retains its own identity. Staff employed are designated to work either in the Ashley or Phoenix unit. A patio and garden provides external space for service users to spend time in a relaxed and pleasant environment. Ashley/Phoenix Unit DS0000040650.V276698.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out over one day. A senior support worker supported the inspector in this process as the Registered Manager was on annual leave. The inspector gathered information for this report form observation of staff interacting and communicating with seven service users, discussions with the senior, five support workers and the activities co-ordinator. Care plans and associated records were examined as were records relating to staff supervision and health and safety practices within the home. The inspector was also provided with a tour of the communal areas of the home and viewed two service users bedrooms. What the service does well: What has improved since the last inspection? Ashley/Phoenix Unit DS0000040650.V276698.R01.S.doc Version 5.1 Page 6 The Statement of Purpose has been updated and now accurately reflects the home’s catering arrangements for service users. The home has recruited several new staff. This will ensure consistency of support for each service user. Money management now forms part of service users care plans. 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.
Ashley/Phoenix Unit DS0000040650.V276698.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashley/Phoenix Unit DS0000040650.V276698.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 5. The home has a comprehensive Statement of Purpose, which provides all prospective service users with sufficient information relating to the service. This should be re-reviewed in accordance with the homes policy. There are contracts in place between the service users and RNID but not between the RNID and Funding Authorities, as there need to be. This remains an outstanding requirement from previous inspections but because compliance with this requirement is outside the control of the manager it is being raised with the Commission for Social Care Inspection’s Provider Relationship Manager as a national issue. EVIDENCE: The manager produced the unit’s Statement of Purpose, which was updated in June 2005 and is a fairly comprehensive document. The details of the new catering arrangements have now been added. This document however should be re-reviewed as the homes policy is to review this 6 monthly and the copy provided to the inspector was dated June 2005. The contact at CSCI should also be updated when this review is carried out. Ashley/Phoenix Unit DS0000040650.V276698.R01.S.doc Version 5.1 Page 9 This will ensure all the information contained in this document is up to date and ensures its accuracy for all service users. Ashley/Phoenix Unit DS0000040650.V276698.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Service users care plans reflect their support needs and goals. Each care plan must be regularly reviewed and updated. Service users are able, with the support of staff, to make decisions about their lives. Specialist forms of communication are used to support this process. The home should review its progress in providing information in accessible formats. The Risk Assessment process supports each service user to take risks. These must be reviewed and updated regularly. EVIDENCE: Three care plans were examined in detail by the inspector. These files are separated into two, “Service Users Care Methodology” and “Evidence File”. These two files contain comprehensive information regarding the current support needs and guidelines for each service user, minutes of review meetings and outcomes, Risk Assessments, activity programmes, contact with
Ashley/Phoenix Unit DS0000040650.V276698.R01.S.doc Version 5.1 Page 11 families and health care professionals, medication profiles, information of particular medical conditions together with historical information. Two care plans also contained several photographs, which helped represent the history of the service users, in a way which was meaningful to them. Another care plan contained an excellent guide to aid signed communication between staff and this service user. This had been developed by the home and included both photographs, the use of BSL symbols from the Link Library and the use of a colour coding system to explain expressive, receptive and contextual signing ability. Each care plan had clear records of the annual multi agency review and the outcomes had been used to update each care plan. There was no evidence however in two of the care plans to evidence these were being reviewed every six months. The home does have a clear process for Keyworkers to follow to ensure these reviews are carried out. This had not been actioned on either care plan. This is essential to ensure that all care plans are kept up to date and accurately reflect the changing needs of each service user. This process also helps to ensure that each service user is supported in a consistent way. Each of these care plans state that written information cannot be adapted into a format which the service user could understand due to their limited communication skills, although there was no evidence to explain how this had been assessed. The inspector questioned this statement and some staff did agree that this should be reviewed as this could be developed for some service users. The inspector observed interaction between support staff and service users at various times of the day as part of the inspection process. This method was used as the service users have limited communication skills and effective communication would require extremely good knowledge of each service user. These interactions demonstrated the staff had a good knowledge of each service users communication method and ability. Various methods were witnessed including British Sign Language, Deaf Blind Manual Alphabet, hands on signing, body language and gestures and clear speech. Staff use these methods to inform service users but make every effort to ensure service users were making informed decisions. The home has developed person centred Risk Assessments to support each person to lead as independent a lifestyle as they are able to. All contained clear information and had been reviewed in July/August 2005. Ashley/Phoenix Unit DS0000040650.V276698.R01.S.doc Version 5.1 Page 12 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14 and 15. Staff support service users to maintain and develop social, emotional, communication and independent living skills. Arrangements are made to ensure that service users have access to, and choose from a wide range of appropriate leisure activities, both on the Poolemead site and in the wider community. Staffing levels at weekends should be reviewed to ensure sufficient opportunities are provided to service users. Service users are supported to develop and maintain relationships. EVIDENCE: The service users are supported to access a range of activities. This work is closely monitored and supported by the activities co-ordinator and the inspector discussed the activities programme with her at length during the inspection.
Ashley/Phoenix Unit DS0000040650.V276698.R01.S.doc Version 5.1 Page 13 Her role is to help plan and facilitate the activities programme for all service users living in the home. She has a good knowledge of each person as she has worked at the home for 14 years and works both weekdays and alternate weekends to support access to the community. Each service user is supported by their keyworkers in the choice and planning of their activities programme. This is devised centred on each individual and new opportunities are being offered. These allow service users the chance to develop, take new risks and experience new activities. Each service user has the opportunity to access the Educational Day Service on the main Poolemead site and the workshop in Wellsway. The records examined confirmed that service users regularly access to woodwork, craft, literacy, art, music, Shiatsu and IT. Independent living skills are promoted within the dayto-day support structure within the home. Community based activities include horse riding, cinema, pub visits, meals out, visiting Victoria Park, trips to the coast, canal barge trips and ice skating. Members of the staff teams have also supported each service user to plan and attend a holiday. These records showed recent holidays to Minorca, Blackpool, Benidorm, Devon and Disneyland Paris. Staff spoken with explained that they work closely with the activities coordinator to ensure that each programme is regularly reviewed and that they can also ask for her to help support activities, if additional staffing is required. It is particularly helpful for her to work on weekends as this gives the service users more opportunity to go on outings. Several staff did express some concern that when staffing levels are reduced, for example if there is no mid shift due to staff sickness, staff holidays or lack of cover, then the opportunities for service users can become limited. The staffing levels on weekends is also remains an issue. The activities co-ordinator works alternate weekends and this therefore increases the staff ratio. The opportunities for service users can therefore be greater on this particular weekend. The home should keep the staffing levels under constant review. Service users should not have their opportunities limited solely due to the management of the staff rota. The rota system employed should be flexible and responsive to the support needs of the service users at all times. Service users are supported to maintain close contact with their families and friends. The care records show that family members regularly attend reviews. A record of correspondence for each service user is also maintained as part of their care plan. Two service users have recently organised holidays in this country, which enabled them to meet up with family members whilst they were away. Ashley/Phoenix Unit DS0000040650.V276698.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. The care plans clearly explain the support each service users requires in relation to their personal and health care. Experienced staff have a good knowledge of each service user and how to provide appropriate levels of support. Any concerns are noted and acted upon. A monitored dosage system of medication for service users is in operation and this is well managed. EVIDENCE: Each service user is registered with a local GP, Dentist and other relevant professionals such as an optician. There are varying levels of support from other health care professionals such as Speech and Language Therapist, Audiologist, and Occupational Therapist. Contact with these professionals was clearly recorded in each service users file and the outcomes acted upon. The inspector observed staff interacting and supporting service users within the home. Staff spoken with displayed a good knowledge of the personal care
Ashley/Phoenix Unit DS0000040650.V276698.R01.S.doc Version 5.1 Page 15 they need to provide to service users and this was in accordance with the care plans examined. The knowledge staff have of each service user is crucial to ensure their health and emotional needs are met. Due to their vulnerability and limited communication skills, service users rely on the support staff to recognise any changes to their usual patterns of behaviour or interactions and these are acted upon. The inspector observed one service user being closely monitored and supported by staff as she had recently been admitted to hospital after a fall. The staff involved demonstrated an extremely good knowledge of the service user and how to offer sensitive care and support to her throughout the day. During this inspection medication on the Ashley unit was examined. This home uses the Boots Monitored Dosage System of medicine administration. The medication records show profiles of each service user, recent photograph, details of their medication, times of administration and manufactures notes on each of the prescribed medications administered within the home. The pharmacist last visited the home in December 2005. Their report confirmed that the medication system was well managed and did not recommend any improvements. Ashley/Phoenix Unit DS0000040650.V276698.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. The RNID has a robust system for dealing with all complaints. Service users are enabled to communicate their views and they can be confident that they will be listened to and their views acted on if necessary. Comprehensive policies and procedures are in place for the Protection of Vulnerable Adults. All staff must confirm they have read and understood these documents. Service users who exhibit behaviour which challenges the service must have clear reactive strategies, which form part of their care plans. This will ensure the safety for service users and staff. EVIDENCE: The home has a complaints procedure, which all service users have explained to them. There have been no complaints recorded since the last inspection. Clear records of all accidents and incidents are maintained. Some service users would be able to communicate to staff members if the were unhappy or felt they were at risk. Others would not have the necessary skills to accurately communicate this. Staff spoken with explained that they therefore also use daily observation when supporting service users. This would help alert them to any changes in behaviour, which may cause them concern.
Ashley/Phoenix Unit DS0000040650.V276698.R01.S.doc Version 5.1 Page 17 The home has comprehensive details of Protection of Vulnerable Adults policies and procedures. These records include each Funding Authority Local Policy, BANES Local Policy and the RNID Policy and Procedure. Staff are asked to read the policies and sign to confirm they have understood them. Only three staff members have currently signed this document. All staff must attend to this as soon as possible to ensure the welfare and safety of service users is promoted. The home has clear policies in place, which are designed to support service users who are distressed, or presenting behaviours which may be perceived as challenging the service provided. Staff are also trained in this area using the NAPPI system. The inspector noted however that one service user who did exhibit physical challenging behaviour towards both her and staff members did not have reactive strategies evident within her care plan. Should any service user require the use of any form of physical intervention, a Risk Assessment must also form part of the behavioural strategy. These must be included in each care plan for the relevant service user. These are essential as they provide a consistent and safe method of support for the service user and the staff team. Ashley/Phoenix Unit DS0000040650.V276698.R01.S.doc Version 5.1 Page 18 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 30. The home is well maintained and has several adaptations, which complement both the skills and abilities of the service users and help to promote their independence. Each service user is supported to decorate and furnish their bedrooms to suit their individual tastes and needs. The home was clean and tidy on the day of inspection. EVIDENCE: The home is well maintained and provides a homely environment for the service users. The decoration shows good use of colour contrasting schemes throughout the units. This is particularly beneficial to the service users who have a visual impairment, as this will enable them to mobilise independently around the home.
Ashley/Phoenix Unit DS0000040650.V276698.R01.S.doc Version 5.1 Page 19 The units also have several tactile features on the walls. This helps to ensure service users can map their environment and helps to provide a stimulating sensory environment. There has been new laminate flooring laid in the lounge area and new dining table and chairs provided in the Phoenix unit. The hallway carpet is being replaced within the next week. This will help to provide an improved environment for the service users. The inspector viewed two service users bedrooms. These were both decorated and furnished to reflect each person’s personal tastes. There were many pictures, photographs and other effects, which show each service users had been supported to personalise their bedroom. One staff member spoken with explained that she was supporting one service user to redecorate and develop a sensory corner in her bedroom. This would enable the service user to have a stimulating and comfortable place to go to spend time on her own, if she chooses to do this. The units were clean and tidy on the day of inspection. Each service user is supported by staff to help maintain the home, with regard to each person’s skills and abilities. Staff are also active in ensuring the home remains clean and tidy. Ashley/Phoenix Unit DS0000040650.V276698.R01.S.doc Version 5.1 Page 20 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 and 36. The staff team remain effective in supporting the service users. Staff are well supported and receive regular supervision to enable them to provide the support to service users. EVIDENCE: The inspector spoke with six members of the staff team during the inspection process. Each staff member confirmed that they enjoyed working in the home and that they felt well supported to perform their duties. It was evident that the home had recent staff shortages, which had led to occasional tensions within the team and had affected the opportunities for service users. Several new staff have now been recruited and are undergoing their induction programme. Once this is completed staff are confident that this will again improve the support and opportunities for each service user. Staff meeting are held on a regular basis in each home and the records examined support this. Staff confirmed that these are useful and informative. They regularly examine or review care plans or methods of approach during meetings. This is to ensure that all staff remain up to date and that these documents are understood. Staff are encouraged to add items to the agenda for discussion if they wish.
Ashley/Phoenix Unit DS0000040650.V276698.R01.S.doc Version 5.1 Page 21 Four staff supervision records were examined. These demonstrated that staff are receiving supervision approximately every 8 weeks. Most meetings were clearly recorded with defined outcomes and action points. Some written records however would benefit from more clarity. Ashley/Phoenix Unit DS0000040650.V276698.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 and 42. The processes of managing the home appear to be efficient and transparent. This helps in providing the support for each service user. There are systems in place designed to promote and protect the health & safety of service users and staff. The Risk Assessment process must be improved and subject to review. EVIDENCE: The atmosphere in both units was positive, with staff committed and focused on the support and care of the service users. Staff spoken with were respectful of the senior management team, and said they receive the necessary support to discharge their job responsibilities and associated tasks accordingly. They found they could approach any member of this team to discuss issues or ask for guidance or support. Ashley/Phoenix Unit DS0000040650.V276698.R01.S.doc Version 5.1 Page 23 The senior member of staff spoken with explained how he was able to play a lead role in staff management and delegated administrative tasks. He was supported to do this by the open and inclusive atmosphere within the home. The home has numerous procedures designed to promote the health and safety of both service users and staff. A number of these were examined during the inspection. COSHH assessments, water temperatures checks and tests on electrical equipment have been carried out. The homes’ accident book was examined, and details of accidents were well documented, with copies placed in individual case file. The home has both generic and person centred Risk Assessments in place. Some of these were found to be out of date as there was no clear evidence of these being reviewed. Also the signing sheet for staff to complete, to confirm they had read and understood each assessment, had not been signed by all staff. This process must be reviewed and improved to ensure the welfare and safety of service users and staff. Ashley/Phoenix Unit DS0000040650.V276698.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 2 X 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 3 34 X 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X X X X 2 X Ashley/Phoenix Unit DS0000040650.V276698.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? YES 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. 2. 3. 4. 5. Standard YA1 YA6 YA23 YA33 YA42 Regulation 4 15(2) 13(7) 18 13(4) Requirement Statement of purpose to be updated in accordance with the homes policy. All care plans to be regularly reviewed and a clear record maintained. Ensure all behavioural strategies are in place to ensure the safety of service users. Staffing levels at weekends to be kept under review. All Risk Assessments must be regularly reviewed and clearly communicated to all staff. Timescale for action 02/05/06 02/02/06 02/03/06 02/02/06 02/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA6 YA23 Good Practice Recommendations The home should review its progress in developing accessible formats for each service user. All staff to read and sign the home’s POVA procedures. Ashley/Phoenix Unit DS0000040650.V276698.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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