Inspection on 21/02/06 for Compass Lodge

This inspection was carried out on 21st February 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Compass Lodge 05/09/06

Compass Lodge 06/09/05

Compass Lodge 11/03/05

Compass Lodge 05/01/05

Compass Lodge 04/03/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

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Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Compass Lodge 121 Abbs Cross Lane Hornchurch Essex RM12 4XR Lead Inspector Mr Roger Farrell Unannounced Inspection 21st February 2006 11:30 Compass Lodge DS0000027841.V284295.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 Compass Lodge DS0000027841.V284295.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. Compass Lodge DS0000027841.V284295.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Compass Lodge Address 121 Abbs Cross Lane Hornchurch Essex RM12 4XR 01708 502179 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) Compass Residential Homes Limited Ms Joanna Martine Smith Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Compass Lodge DS0000027841.V284295.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th September 2005 Brief Description of the Service: Compass Lodge is a private registered care home that accommodates and supports four people who have learning disabilities. The owners operate two other smaller homes in the neighbourhood. Historically one manager has been responsible for this house, and Compass Cottage, a short walk away further along Abbs Cross Lane in Hornchurch, and this remains the case. Compass Lodge has been operating for over ten years. The property is a semi-detached house, set back from the busy road. The front entrance has steep circular steps, but easier access is possible at the side, including a narrow ramp to a side door. The communal room is a combined lounge diner. The dining area is a bit cramped and has poor natural light, but overall the home is quite homely. All residents have single bedrooms, with one on the ground floor and three upstairs. These are well decorated and reflect the individuality of each person. There is a pleasant rear garden with a patio, and a small decked area. The former garage to the side has been split to create a laundry and storeroom, with the other half converted as the office. The neighbouring property is a subpost office and shop. Good standards of cleanliness are maintained, and this is a consistent finding at unannounced visits. This home is about a mile from the shops and other facilities of Hornchurch town centre. Compass Lodge DS0000027841.V284295.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 11.30am and 2.15pm on Tuesday 26 February 2006. All three homes in this group were visited on the same day. Jo Smith, the registered manager for Compass Lodge and Compass Cottage was available throughout the day and took the lead in dealing with the enquiries about these two homes. She was also present for part of the inspection of Compass Grove, as she supervises the manager of that home. All four residents were at home and welcomed the inspector. The last inspection of this home was an announced visit on 6 September 2005. At that time most of the standards were covered. A copy of that report is available at the home, and can be found on www.csci.org.uk. This visit concentrated on looking at the five requirements from the last report, looking at staff team continuity, and an update on how residents spend their time. The inspector explained the changes in how homes will be monitored from April 2006. This includes managers needing to be better prepared to show how internal checks and monitoring are taking place. Managers and owners have now received a letter setting out the new approach and the changed frequency of visits. What the service does well: What has improved since the last inspection? Clearly, the headline positive finding of this visit is the improved in staff retention. Last year a relative wrote – “I know [my relative] is generally cared for well which is the most important thing, but I wish the staff would not change so rapidly, there is no consistency”. Another comment was – “At Compass Lodge staff come and go.” In addition to saying she was very Compass Lodge DS0000027841.V284295.R01.S.doc Version 5.1 Page 6 pleased with the low staff turnover during the last nine months, the manager praised the caring approach of her staff. As well as providing better consistency for residents, it allows her to plan a more confident approach to training. This improved stability means that they can work towards achieving the expected 50 quota of qualified care staff. The manager is doing the Registered Manager’s Award. 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. Compass Lodge DS0000027841.V284295.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 Compass Lodge DS0000027841.V284295.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 5. The inspector was shown the guidelines on assessment and move-ins that would be followed should a vacancy occur. This would need to make sure any new person would get on with the existing residents. EVIDENCE: There have been no new admissions to this home since March 2002. The inspector had been shown the documentation ready to be used in future for assessment should a vacancy occur. This included the NCHA’s standardised ‘application form’ and the ‘assessment schedule’. However, last year the inspector raised major concerns about the poor planning around an attempt to quickly move a new resident into Compass Grove. The company were told that they must have a much clearer policy and procedure on assessment and move-ins, clarifying the central decision-making responsibility of the registered manager. There are now a series of documents that he was assured would be used as the framework in the future. These include a ‘pre-service and needs assessment’; ‘trial periods’; ‘admission procedure’; and move-in checklists, all adopted from the ‘Mulberry’ series. These set out a responsible approach to introducing prospective residents. The assessment standard is rated as met as it accepted that the company will follow these guidelines in the future. The manager said the Compass homes do not accept emergency admissions. There are now contracts covering each person’s terms of residency. Compass Lodge DS0000027841.V284295.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 and 9. These standards were covered at the last visit, the report saying the gradual improvement in how service user files are maintained helps show that day-today care is now better planned. However, at this recent visit confirmation that main annual reviews are being held was requested, and this is an area that has slipped. EVIDENCE: The practice files are modelled on the ‘person centred planning’ approach, and have sections that seek to establish the choices of residents, such as the ’likes and dislikes’ and ‘what I need help with’. The main section of the files is a series of ‘care-plan’ sheets covering a range of general headings, including health; mental health needs; mobility; personal care; communication skills, and so on. These identify individual needs, and then set out the support that is needed, including giving practical guidance. Last year there were copies of reviews on the service user files seen, the manager saying there had been a main review for each person with their placing social services during that year, there being pre-review in-house resumes. Conformation was now only available of one resident having a main Compass Lodge DS0000027841.V284295.R01.S.doc Version 5.1 Page 10 review within the last twelve months. A requirement has been set on this matter. Other sections were being introduced into the service users’ files. This included ‘skills teaching monitoring forms’ and a ‘My Life Plan’ section. Whilst the gradual improvement in introducing more up-to-date practice notes was welcomed, a need to include risk assessments was set as an area to be improved. For instance, there was no such assessment for one person who has mobility problems, though there was a quite recent physiotherapist’s report. At this visit some examples of risk assessments were seen, such as on giving help with personal care. However, the important area of mobility had still not been completed. More work is needed in this area, and the requirement has been carried forward. The manager and team have been dealing with a sensitive matter to do with one person’s contact with their family. The manager is clear in the approach that has been adopted to support the wellbeing of this resident, and has maintained contact with the social workers. One of the registered owners is a practicing speech and language therapist and a Makaton tutor. Care-plan files contain communication assessments, which she had carried out. The manager is able to clearly describe each resident’s communication abilities. Two residents have limited verbal skills, though sections in the care plan files show good efforts to establish preferences and determine how choices may be expressed. Communication cue cards are available. Compass Lodge DS0000027841.V284295.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): 12, 13, 14 and 15. There is some evidence of improved opportunities. This includes an art therapist visiting one resident for two sessions each week. These standards will be covered at the next visit, including looking at how regularly events set out on the ‘weekly planner’ are taking place. EVIDENCE: This service’s scope has been limited in the past due to problems maintaining a stable staff team. This has meant that maintaining day-to-day domestic routines was generally all that could be achieved. With improved team stability, there is now more scope for helping residents have improved social and leisure opportunities. Three of the residents who live here have quite high dependency needs, such as with personal care and going out. One person is nervous about leaving the building at times, and needs a flexible service to respond when he chooses to go out. Another person has limited mobility. Relatives have raised the need for residents to have more activities. There is evidence that things are moving in the right direction. For instance, the most dependent resident now has a Compass Lodge DS0000027841.V284295.R01.S.doc Version 5.1 Page 12 visiting art therapist twice a week, and she was at the home on the day of this visit. There is an ‘activities plan’ and notice board in the lounge, and sheets recording who has taken part in the programme. The ‘service user files’ have better details about social and leisure activities, such as reports from holidays and outings. However, this is an area that will be looked at more closely at subsequent visits, notably what opportunities the more dependant residents have to get out and about. The manager gave assurances that the resident who needs soft food was receiving sufficiently varied and suitably presented meals. Her dietary needs are covered in the care plan, and a record of meals is kept. Compass Lodge DS0000027841.V284295.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): 19 and 20 Details kept on residents’ files, such as the ‘tracking sheets’ show good monitoring of health care needs. The care plan are good at specifying what help each person needs with their personal care. EVIDENCE: The care-plan files have a ‘my medical details’ section, with good tracking sheets for contacts with doctors and other health care workers. All residents need to be accompanied to all medical appointments. The two GP practices used are described as helpful. Files have a good range of assessments and reviews from health care workers, including a psychiatrist, occupational therapists and physios, as well as the speech therapist referred to earlier. The medicines cupboards are now in the hall instead of the outside office. The medication administration files now have individual profiles, and instructions to follow if an error occurs – though no mistakes are known to have occurred in the past year. Following the check on medication arrangements last September, the manager was asked to make sure that old stock was sent back to the pharmacy. This is being done, and all the medication cassettes in the office awaiting return were empty. Compass Lodge DS0000027841.V284295.R01.S.doc Version 5.1 Page 14 A local pharmacist supplies medication in blister packs, with printed administration sheets. This pharmacist also provides training sessions, and all staff have to complete a competency test before being responsible for giving drugs. The pharmacist visits and checks the medication arrangements about every three months and leaves a report. Compass Lodge DS0000027841.V284295.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. The manager is aware of the expectations about recording, reporting and following through on complaints and any allegations of abuse. The necessary range of guidance is available. At this visit the manager was able to describe a more thorough approach to following through complaints, the two matters in question having taken place at the sister home, Compass Cottage. EVIDENCE: The manager gave the inspector an update on a matter dealt with through their protection procedures. A staff member had not followed the expected procedures when applying for store cards for resident at Compass Cottage. The matter was reported to the police, but no fraud was found to have taken place. The staff member was suspended and referred to the temporary POVA list. The person has not worked at the homes since the irregularity was found. There is available a file containing the required range of policies and guidance covering protection issues and responses. This includes a copy of ‘No Secrets’; the in-house policy and ‘Pavilion Pack’; and the Havering guidelines. All individual staff training profiles seen included confirmation that they have attended a training day on this topic, the last having been the previous month, which was led by one of the owners. Staff who had attended that session completed an evaluation form. Compass Lodge DS0000027841.V284295.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, 25, 26, 27, 28 and 30 The house is well maintained, homely, with good standards of cleanliness. This was reflected in an infection control and hygiene audit carried out last year independent consultant. EVIDENCE: This semi-detached property is set well back on a rise away from the busy Abbs Cross Lane. The neighbouring property is a sub-post office and handy general store. The premises is generally well maintained, and was found to be bright and clean - which is a consistent finding, including at unannounced checks. The last inspection by an EHO was in April 2004, with conditions recorded as ‘satisfactory’. A Fire Safety Inspector last checked arrangements in June 2004, his report recording good safety arrangements. The combined area of the lounge/diner provides space that exceeds the minimum required level. These are comfortably arranged with a good range of homely touches, including photos, and entertainment equipment. The kitchen was found to be clean and safely arranged. The garden has a small patio with furniture and a separate small area of decking. The laundry is part of the former garage, with a separate section used as the office. Compass Lodge DS0000027841.V284295.R01.S.doc Version 5.1 Page 17 The inspector was shown all bedrooms. All have a good standard of cleanliness and décor and show a high level of personalisation, such as photos, trophies, and home entertainment equipment. The bathroom is on the first floor, adjacent to the three upstairs bedrooms. There is a shower room on the ground floor with a toilet and hand washbasin. The shower is a cubicle with a step-in base. For some time there has been a plan to change this to a walk-in version. The manager said that she anticipated this improvement taking place this spring. Compass Lodge DS0000027841.V284295.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): 32, 34 and 35. Last year’s inspection reports said that the biggest problem was keeping staff. The main positive finding at this visit was that staff retention has improved considerably. EVIDENCE: There is an overlap between the staff that work in this home and at Compass Cottage. The staffing complement for Compass Lodge and Compass Cottage combined is – manager; full-time deputy; 2 full-time assistant deputy managers; 1 full-time senior care assistant; and 5 full-time and 5 part-time care assistants, of which 4 cover night shifts. Cover in this house is 2 staff on duty on the early and late shifts (7.30am to 10.00pm), not including the manager. Night cover is one waking person. Current rotas show occasional ‘long-shifts’, though these are said to be voluntary, and are followed by a day off. The good news was that no staff have left since the last inspection, other than one person being dismissed. Fifty per cent of staff have been with the company for over a year, with nearly all others having started in early summer last year. This compares very favourably with the position reported earlier last year. Compass Lodge DS0000027841.V284295.R01.S.doc Version 5.1 Page 19 At that time the manager’s main frustration was that the time being spent on early stage induction and subsequent training was largely being lost. The owners were asked to examine the issue of staff turn-over, but the subsequent report said their brief response sidestepped this issue, saying nothing worthwhile about how this problem was to be addressed. Nevertheless, the current profile is much better. This improved stability means that the manager can proceed with a more planned strategy for training. The training profiles for the longer serving staff show that they have covered the main core areas such as food hygiene, fire safety, medication, first aid, and manual handling. The inspector saw examples of recent training needs assessments done in supervision. However, the expectation is that care homes should by now have reached the target of 50 of staff with a relevant qualification. Details provided by manger show that only two staff have an NVQ at Level 2 or 3, with four currently on such a training scheme, including the deputy of this house. One further person was due to start on an NVQ scheme. Reasonably regular staff meetings are occurring, and these are now for staff from all three of the company’s homes. The manager explained how an ‘Employee of the Month’ scheme was working. The manager is good at carrying out the required range of vetting - such as getting two references, a CRB certificate, and checking permission to work. The well arranged staff files have a training profile, induction checklist and copies of course certificates. This reflects the positive steps that have been taken over the last couple of years to have records that meet the standards. The manager is now aware of the ‘PovaFirst’ fast checks. At this visit there was one outstanding CRB check, an application having been submitted last September. This person was only working at this home as it does not involve ‘single-handed’ shifts. One other person was soon to be twenty-one, meaning that she could work at the other homes. Compass Lodge DS0000027841.V284295.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. There is generally adequate evidence to support the standards tested under this heading. The manager is based in this house, visiting the twinned house a couple of times a week. She expresses a high level of satisfaction with the deputy, who returned to this home last year following a break. EVIDENCE: The manager has fifteen years experience in the care sector, eight of these in a management position. She commenced with this company in January 2001, managing the smallest of the group of three homes. She took on manager responsibilities for Compass Lodge and Compass Cottage in January 2003. Her title is now ‘Area manager’ as she supervises the manager of Compass Grove. She has got the NVQ level 3 Award. She is due to complete the RMA Award in July 2006. The owners and manager carry out spot-checks, including at nights, and take action where they find deficiencies. The owners use a tick and comment ‘monthly report’ format produced by the NCHA, and have done brief business Compass Lodge DS0000027841.V284295.R01.S.doc Version 5.1 Page 21 plans. At announced inspections the owners have made available information from their accountants confirming the viability of the business. At his last visit the inspector asked to see a range of records and certificates covering health and safety. This included tests of the alarms and the fire drills; contractor tests of the extinguishers; electrical and gas certificates; and information on Coshh materials. These were all satisfactory. Reports of the last visits by a fire safety inspector and environmental health said conditions were fine. The one area needing improvement was to resume health and safety checks as these had lapsed. The deputy is doing these. Compass Lodge DS0000027841.V284295.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 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 3 X 3 X X X X X X Compass Lodge DS0000027841.V284295.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? Yes – items 1 and 2 are carried over. 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 YA6 Regulation 13(4(c) Requirement As appropriate, include in service users file risk assessments in key areas such as mobility needs within the home and when going out. Ensure that staff have sufficient training in the core areas, and that there is a plan working towards the target of staff holding a recognised qualification. At least once a year hold a meeting with relevant professionals, family or other representatives that reviews the service and facilities being provided to each service user. Have a record of these meetings on the service user’s file. Timescale for action 30/05/06 2 YA32 18 30/05/06 3 YA6 15(2)(b) 30/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Compass Lodge DS0000027841.V284295.R01.S.doc Version 5.1 Page 24 Compass Lodge DS0000027841.V284295.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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. Extracts may not be used or reproduced without the express permission of CSCI Compass Lodge DS0000027841.V284295.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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