Inspection on 11/01/06 for Browfield Residential Care Home

This inspection was carried out on 11th January 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Browfield Residential Care Home 05/11/08

Browfield Residential Care Home 22/11/06

Browfield Residential Care Home 08/08/05

Browfield Residential Care Home 14/03/05

Browfield Residential Care Home 22/09/04

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Sunny Bank (P.R.S.) Ltd

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Thornton Lodge

Alfred House Residential Care Home

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Thames House

Creative Support

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

CARE HOME ADULTS 18-65 Browfield Residential Care Home 159/161 Walmersley Road Walmersley Bury Lancs BL9 5DE Lead Inspector Lucy Burgess Unannounced Inspection 11th January 2006 09:30 Browfield Residential Care Home DS0000008421.V265738.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 Browfield Residential Care Home DS0000008421.V265738.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. Browfield Residential Care Home DS0000008421.V265738.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Browfield Residential Care Home Address 159/161 Walmersley Road Walmersley Bury Lancs BL9 5DE 0161 797 8457 0161 797 8457 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) Mrs Jacinta Rosaleen Ormerod Mrs Margaret Elizabeth Motby Care Home 14 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (4) Browfield Residential Care Home DS0000008421.V265738.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home is registered to a maximum of 14 service users to include: Up to 10 service users in the category MD (Mental Disorder excluding learning disability or dementia under 65 years of age). Up to 4 named service users in the category MD (E) (Mental Disorder excluding learning disability or dementia over 65 years of age). The service should employs a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 8th August 2005 2. Date of last inspection Brief Description of the Service: Browfield is a residential care home providing accommodation and support for up to fourteen people who are recovering from a mental illness. The home is registered to provided support for up to 4 people over the age of 65 years. The property comprises of two large terrace houses, which are adjoining. Accommodation is provided on three levels and includes 10 single bedrooms and 2 double rooms. There are 3 lounges and a dining room. The home is situated on a main road approximately 1 mile from Bury town centre and is easily accessible for public transport. Local shops, pubs and other amenities are situated nearby. Browfield Residential Care Home DS0000008421.V265738.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over one day for a period of 4.5 hours. The inspector took the opportunity to look round the home, view records as well as talk with a resident. Discussion and feedback was also held with the Manager. The home is registered to provide accommodation for up to 14 people. At the time of the inspection there were no vacancies. Not all the standards were looked at during this inspection. Those key standards not addressed at the last inspection as well as action identified were followed up during this visit. What the service does well: What has improved since the last inspection? Information needed when starting new staff had been placed on file along with the checks ensuring residents are protected. Files are in place for each member of the team. A number of training courses have been held for the staff. These have included adult abuse, fire, dementia, moving and handling, medication, health and safety and fire safety, providing them with the skills needed to do their jobs. The medication system had been improved. Items were stored safely. Records had been made of all items received or returned to the chemist. Staff had received the training needed in handling medication so that the practice followed is safe. Browfield Residential Care Home DS0000008421.V265738.R01.S.doc Version 5.1 Page 6 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. Browfield Residential Care Home DS0000008421.V265738.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 Browfield Residential Care Home DS0000008421.V265738.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): 2 and 4 The system of assessing prospective residents as well as spending time with them prior to admission gives an assurance that a resident will only be admitted if the home can meet their needs. EVIDENCE: Information was seen for the newest resident. Assessments had been carried out by the relevant health and social care professionals outlining the emotional, physical and mental health needs of the individual. These documents had been received by the home prior to the placement being formally agreed. This enabled the manager to make an informed decision about whether needs could be met at the home. Arrangements were also made for visits to the home as well as overnight stays. Several visits were planned prior to moving in and enabled the resident to meet and spend time with other residents and staff getting to know them. Following the trial visits it was agreed by all parties, including the resident that the placement could meet the identified needs. This would be reviewed again over a period of time ensuring the resident had settled. Browfield Residential Care Home DS0000008421.V265738.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Care plans and risk assessments are in place however up to date information reflecting the care needs of the newest resident was needed providing staff with clear information about how needs should be met. Residents appeared well cared for and were clearly involved in making decisions about their lives. EVIDENCE: Individual care plans and risk assessments are in place for each of the residents. Information was examined for the newest resident. Assessments and a background history had been accessed from the funding authority however this had not been used to inform the development of a care plan. The manager explained that she was to meet with the social worker and resident in order to gather up-to-date information prior to writing the plan. As the resident has now been at the home for approximately 10 weeks a plan of care along with relevant assessments need to be completed providing staff with the relevant information required in meeting his needs. Plans are reviewed regularly or as needs change. This was evidenced on those files seen. Formal reviews are also held with mental health professional as Browfield Residential Care Home DS0000008421.V265738.R01.S.doc Version 5.1 Page 10 part of the discharge programme and information is held on file. It is suggested that plans are signed by the residents to evidence their involvement and agreement. Risk assessments are completed where a specific concerns have been identified. It was noted that due to concerns raised by staff in relation to family contact a review was held so that arrangements could be made to ensure the residents safety and well-being. Appropriate action was taken by the home and agreements made with the funding authority. This information was held on file. Where concerns are noted in relation to the mental health of a resident the mental health professional involved would be notified. The Community Psychiatric Nurses (CPN) and hospital consultants continue to provide on-going support and advise to the team. Additional records continue to be completed. These include a communication diary for each of the residents, which is completed by the staff on a daily basis. This enables information to be passed within the team of individuals’ daily activities, if any issues have arisen or for monitoring purposes. The manager still completes a weekly update, summarising events from the previous week and if any follow up action is needed. Any action required by staff is highlighted, this information is read by the staff before starting their shift ensuring they are up to date with current needs and the support to be offered. Residents are able to make decisions about their lives enabling them to increase their independence. Residents are able to come and go freely pursuing activities of their choosing and this was observed during the inspection. Most of the residents follow various leisure activities preferring not to undertaken formal course or therapeutic employment opportunities. Daily routines are based on individual preferences, age and motivational levels. Interactions with staff were seen to be open and friendly. Residents felt they could speak with the manager and staff in confidence. Staff have a good awareness of individual needs. Information regarding the residents is held securely within the staff office. This is accessible to staff to refer to throughout the day. Browfield Residential Care Home DS0000008421.V265738.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 13, 14 and 15 Routines vary depending on individual choices and preferences. Residents access the local and wider community enabling them to lead valued lives, develop skills and increase their independence. Support is offered where required. Residents maintain contact with family and friends and open visiting is encouraged. EVIDENCE: The home is a large property however is indistinguishable from those around it. It is easily accessible to Bury town centre and is situated close to the main bus route. Residents have bus passes, which enables then to travel independently visiting the local town centres as well as friends and family. Support is offered to those who require additional support. Routines at the home vary depending on individual wishes and motivational levels with individuals rising and retiring as they wish. Residents pursue activities both in and away from the home and staff offer encouragement in maintaining their independent living skills. Individuals continue to have Browfield Residential Care Home DS0000008421.V265738.R01.S.doc Version 5.1 Page 12 regular access to community facilities accessing local shops, post offices and park. Residents also have a variety of items such as televisions, videos and stereos, which they can relax and listen to. As a number of the residents prefer to spend most of their time within the home, the manager has ordered a games table for the home, this will enable residents to play table football, pool and several others games, encouraging interactions with each other as well as 1-2-1 with staff. At present residents generally choose not to pursue formal courses or therapeutic employment. One individual however does attend a local day centre each week. Arrangements are being made for the newest resident to join the local centre as well as visit a drop in centre so that he can develop new skills and friendships. Five residents have recently enjoyed a holiday in Blackpool. A further trip is to be planned in the summer. Separate holidays are also agreed for those individuals who require less support. Residents continue to maintain contact with family and friends. Visits take place both at the home or with residents visiting family members. Contact is made on a regular basis. Residents have the freedom of movement around the home as well as coming and going as they choose. Browfield Residential Care Home DS0000008421.V265738.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 and 20 Residents health and personal care needs are consistently met ensuring their well-being is maintained. Relationships with mental health professionals are effective and provide positive support networks for the residents ensuring their health needs are promoted. The medication system was found to be safe and staff have completed training ensuring residents are protected and practice is safe, minor improvements were needed to the records. EVIDENCE: Information is held in relation to the mental and physical health needs of residents. Health care professionals are accessed for additional support and advise ensuring sufficient support and monitoring is provided in meeting the needs of residents. Formal reviews as required under the discharge programmes are held and discussion includes the residents’ stability, progress or concerns in relation to their mental health. Further information is also recorded within the care plans outlining the specific support needs of individuals and how they are to be met giving clear directions to those offering support. Browfield Residential Care Home DS0000008421.V265738.R01.S.doc Version 5.1 Page 14 Records are made of all professional visits and appointments, which include community psychiatric nurses, opticians, GP, hospital etc. Each resident has access to all NHS entitlements as and when they are needed. Support is offered for appointments. Additional records are made with regards to monitoring the dietary needs of individuals particularly where a need has been identified and periodic weight records. Staff provide personal care support in varying degrees. This is very much dependent on individual needs. In the main residents are prompted in maintaining their own personal care. Bathing and toileting facilities are provided on each floor and are easily accessible to each of the residents. The medication system was looked at. A recent visit had taken place by the supplying pharmacist and a record of the visit held at the home. Records are also made of all medication received into the home as well as those items returned to the supplying pharmacist. On examination of records these were found to be update and where changes had been made staff had signed to evidence why. In relation to the controlled drugs register it was noted that initials were being used as opposed to the full name of the resident and that details of what medication being administered had not been detailed at the top of each page. This information should be detailed in full evidencing the medication being administered and to whom. Staff have received the relevant training required. Residents’ medication is also regularly reviewed with health professionals ensuring the stability of their mental health. One of the residents is currently being supported in administering her own medication as part of her programme. At present items are still held by staff but then the resident is supervised in taking what is prescribed. This is a programme of development currently being supported by staff as it is planned that the resident will soon move on to a supported tenancy. A risk assessment has been completed detailing the current programme of support. Browfield Residential Care Home DS0000008421.V265738.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Systems are in place with regards to the investigation of complaints and adult protection issues, ensuring that residents were listened to and protected. EVIDENCE: Clear policies and procedures are in place covering these standards. No complaints have been received either by the home or CSCI. A copy of the Local Authorities Vulnerable Adults procedure has been accessed. The team have some knowledge in relation to the procedure to follow and training has been completed, evidence was available on file. Residents are clear about what they could do if they had any concerns or complaints and regular access the manager, owner and staff if they wish to discuss any matters. The home also has further written policies and procedures for adult protection these include dealing with whistle blowing, aggression, service users finances and missing person. Browfield Residential Care Home DS0000008421.V265738.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 Browfield continues to provide a comfortable, clean and homely environment for the residents living there. On-going work to the environment has made improvements to the environment. EVIDENCE: Browfield is a large property that is in keeping with those around it. All but two of the bedrooms are single, with only one having en-suite facilities. On-going refurbishment and redecoration has taken place. This has enhanced the environment. Work has been completed in the dining room and smoke lounge, these have been repainted and fitted with new curtains. Two further bedrooms have also been redecorated. Further work is being undertaken in another bedroom with new flooring and furniture on order. The home also has a dining room and three lounges, two of which are the designated smoking areas. Residents were seen to spend time relaxing in all areas. A separate office is also provided. There are two bathrooms as well as the en-suite bathroom with walk-in shower on the ground floor. Browfield Residential Care Home DS0000008421.V265738.R01.S.doc Version 5.1 Page 17 The home employs designated domestic staff that undertake a majority of the domestic tasks, however additional tasks are carried out by the support staff. The environment was seen to be clean and odour free. Browfield Residential Care Home DS0000008421.V265738.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34, 35 and 36 Staff at the home are in sufficient numbers to meet the needs of residents. On going training is provided to equip staff with the knowledge and skills needed in meeting the needs of service users. Recruitment and selection procedures are followed ensuring the residents are protected. EVIDENCE: Staffing levels are sufficient to meet the needs of the residents. The majority of staff have worked at the home for a number of years therefore have developed good working relationships with each other. From observations made the rapport between residents and staff was relaxed and friendly. Where a recent issue had arisen between staff members this had been formally addressed with the manager and owner and records made of all meetings held. The staff team is small and consistent with little turnover. A new member of the team has recently been recruited in the role of the domestic. Information had been gathered as part of the recruitment process and included an application form, full employment history, health declaration, identification and references. A copy of the criminal record check carried out by the home was also examined. The manager is aware of the procedure to follow with regards to accessing checks prior to individuals commencing employment. Browfield Residential Care Home DS0000008421.V265738.R01.S.doc Version 5.1 Page 19 Various training courses have been provided for the team, these have included food hygiene, moving and handling, protection of vulnerable adults, medication, health and safety, fire safety and dementia. Further training has also been identified with regards to challenging behaviour, anxiety and depression and medication. Copies of training certificates are held on individual files. Staff training has also been provided with regards to the NVQ courses. A number of staff have recently achieved Level 2. Those who have yet to undertaken the training will do so over the coming year. The new domestic staff is also to complete an NVQ relevant to her role and responsibilities. The manager has already achieved the Level 4/Registered managers Award. A supervision system is in place. However on examination of the records it was noted that whilst some staff had met with the manager on a frequent basis others had not. Additional support had been provided for those completing the NVQ. The manager has developed a supervision sheet, which is to be completed by all staff throughout the year, outlining if staff have any issues or matters to discuss and whether they wish to meet together. Whilst this will allow the manager to gather feedback from staff this should not replace the formal 1-2-1 meetings. Periodic discussion should be held with all staff in line with the standard ensuring open communication as well as discussion around further training and development. Occasional team meeting are also held, and minutes are recorded. Browfield Residential Care Home DS0000008421.V265738.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The overall management of the home is consistent and reliable for the people living there. Systems are in place for the reviewing of the service provision. A report regarding quality assurance should be developed and shared with all parties. Satisfactory arrangements are in place with regards to providing a safe, well maintained home so that residents and staff are safe from harm. EVIDENCE: The Residential Manager is responsible for the day-to-day management of the home. Training with regards to the Registered Managers Award and NVQ level 4 have previously been completed. Other training courses related to the needs of service users have also been completed ensuring that her practice is up-todate. The manager is supported in her role by the owners. Monthly reports are undertaken by the provider and information available for inspection. Although there is no formal system in place for gathering feedback from stakeholders with regards to the overall service provided information is Browfield Residential Care Home DS0000008421.V265738.R01.S.doc Version 5.1 Page 21 gathered in a number of settings. Residents have regular contact with the manager and owner and feel able to discuss any matters or ideas they have. Residents were said to prefer the informality of 1-2-1 discussions as opposed to meetings. Where possible the manager tries to speak with each resident on a weekly basis. Feedback is also sought from the staff during the periodic team meetings and supervisions. Information is recorded and used to inform areas of development for the home. Feedback is also received during the residents review meetings, which involves health and social care professionals. It is suggested that a report in respect of all quality reviews is written outlining the development plan for the home and made available to all interested parties. Up to date certificates were seen for the 5-year electric checks, gas, fire appliances and alarm, emergency lighting and small appliances. Regular inhouse checks are also made with regards to sounding the fire alarms, checking means of escape and fire drill, the most recent being November 2005. Records are also held in relation to water temperature and fridge and freezer temperature. The home has also recently been inspected by the Fire Officer and Food Safety Officer. Browfield Residential Care Home DS0000008421.V265738.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 3 36 2 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 X 13 3 14 3 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X 2 X 3 X 2 X X 3 X Browfield Residential Care Home DS0000008421.V265738.R01.S.doc Version 5.1 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. 1. Standard YA7 Regulation 15 Requirement That a detailed care plan is developed for the newest resident providing staff with clear information about the needs, which are to be met. That full names are recorded within the controlled drug register instead of initials That the name and dose of the medication being administered is recorded at the top of the controlled drug register. That formal supervision is held with all staff a minimum of 6 times per year and evidence is provide of such meetings. Timescale for action 28/02/06 2. 3. YA20 YA20 13 13 01/02/06 01/02/06 4. YA36 18 28/02/06 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 YA7 YA39 Good Practice Recommendations That service users sign care plans to evidence their involvement and agreement. That a report in respect of all quality reviews is written outlining the development plan for the home and made available to all interested parties. DS0000008421.V265738.R01.S.doc Version 5.1 Page 24 Browfield Residential Care Home Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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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