Inspection on 18/10/06 for Creek Road (79)

This inspection was carried out on 18th October 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

Creek Road (79) 10/04/07

Creek Road (79) 21/02/06

Creek Road (79) 28/06/05

Creek Road (79) 21/12/04

Creek Road (79) 12/08/04

Creek Road (79) 11/03/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Creek Road (79) March Cambridgeshire PE15 8RE Lead Inspector Dragan Cvejic Unannounced Inspection 18th October 2006 09:00 Creek Road (79) DS0000015296.V316805.R01.S.doc Version 5.2 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 Creek Road (79) DS0000015296.V316805.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Creek Road (79) DS0000015296.V316805.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Creek Road (79) Address March Cambridgeshire PE15 8RE 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) 01354 654575 Conquest Care Homes (Peterborough) Limited Janice Cross Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Creek Road (79) DS0000015296.V316805.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st February 2006 Brief Description of the Service: 79 Creek Road provides accommodation and support to four adults with mild to moderate learning disabilities. All those living in the home are female as are the two support staff. The home is in an ordinary house in a residential area of March close to local amenities. Each bedroom is for single occupancy and each has a washbasin. Service users share the bathroom facilities, the lounge, and the kitchen and dining area. To the front of the building is a parking area; to the rear is an enclosed garden. The home is provided by Conquest Care Homes which is a trading subsidiary of Craegmoor Healthcare Ltd. The average fee was £319, calculated from the lowest £ 288.84 and the highest £344.79. Creek Road (79) DS0000015296.V316805.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection. The site visit was carried out during 2 hours on the first day when no service users were present. The second visit was therefore carried out starting from 16.30 and lasted for 3 hours, when all service users were present. Two users’ files were checked. Both staff were spoken to. Some policies and procedures were checked. A tour of the house was also undertaken during the second visit. Service users were observed doing normal house routine chores. Three service users were spoken to, and one was a bit unwell and remained in her room. Both staff members were spoken to. What the service does well: What has improved since the last inspection? What they could do better: Creek Road (79) DS0000015296.V316805.R01.S.doc Version 5.2 Page 6 In service users’ files, contracts or licence agreements were not signed by service users or their representatives. Also the room number was not recorded on this document, as in such a small home, rooms were not numbered. However, the manager stated that the rooms would be numbered and numbers recorded. The cooker in the kitchen needed to be replaced, as it had a broken metal plate seal. The carpet in the lounge was not replaced despite repeated requirements from the inspectors. This requirement stayed after this inspection, but with a short time scale. Although some comments about satisfaction with services and provisions were collected through questionnaires, these were usually given to relatives and not regularly to service users. A full quality assurance system was not in place. There were only two staff working in the home, the manager and the support worker. Service users’ needs were met only with staff commitment and flexibility to cover shifts whenever it was necessary, as well as staff readiness to respond at any time in case of an emergency. The Resident Forum formula for staffing hours and number suggested that 2.58 staff were necessary. Three service users spoken to suggested that another member of staff was necessary, to “be fair” to existing staff. The staffing number was addressed as a requirement on the previous inspection. The manager’s hours were set as care hours without the time set to carry out management duties, being the only staff on site on her shifts. The home obviously needed another member of staff, at least for some set hours and weekends. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Creek Road (79) DS0000015296.V316805.R01.S.doc Version 5.2 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 Creek Road (79) DS0000015296.V316805.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided good information about the services and provisions and allowed users to decide for themselves if they wanted to move in and live in this home. They offered a place only after they collected sufficient information enabling the home to decide if they could meet the prospective user’s needs. EVIDENCE: The manager reviewed the Statement of Purpose and displayed it in the porch, making it accessible for service users, visitors and professionals visiting the home. The Statement was framed and even looked nice on display. Service users knew and were aware of their rights, expectations and duties in the home. The contracts listed the responsibilities and rights of service users. It also had added contracts from social services showing fees. The contracts seen were not signed by service users. Initial assessment records were in users’ files and contained sufficient information. The newest user’s file was case tracked and showed that all necessary information was obtained prior to offering her a place in the home. Creek Road (79) DS0000015296.V316805.R01.S.doc Version 5.2 Page 9 She stated: “I am so lucky I have got a place here, I had to wait for a long time for it.” Service users stated that their needs were met. Observing the afternoon during the visit also indicated that users’ needs were met. Creek Road (79) DS0000015296.V316805.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users individuality, choice and decision making were very much respected and promoted. Users were given the chance to control the level of these standards and clearly showed how these standards could be exceeded. EVIDENCE: Service users care plans were appropriate, recorded their needs and were regularly reviewed and updated when the change in users condition was identified. The home planned to further improve care plans by reorganising how the needs and actions were presented. Two files checked also recorded the issues that users could not manage themselves, such as controlling the users’ finances. The home used a “person centred planning” approach whereby the goals were set for each user. The manager and users confirmed that the best method for them to understand their plans was to discuss them with the manager or the staff. Creek Road (79) DS0000015296.V316805.R01.S.doc Version 5.2 Page 11 Service users were enabled to make their own decisions. They chose their daily routine and were fully in control of their lives. A service user hoped to improve and eventually move on to a fully independent accommodation and she was supported by staff, discussed the possibility with her social worker and felt respected. The home demonstrated that they were very strong in encouraging users to make their own decisions and exceeded standards. Participation in the home was another strong element demonstrating how users could influence their own life in what they saw as their home. Three of them looked at the staffing structure and made very reasonable comments and explanation of the staffing cover for this home. They also presented how they communicated with each other the staffing hours issue. This standard was well exceeded. Service users demanded to be allowed to take a risk and they were well supported to do that. They were also aware of the limits due to their conditions and these were recorded in their files. The risk was appropriately assessed and recorded with full respect for each individual service user. This standard, especially related to the individuality of service users was also exceeded. Creek Road (79) DS0000015296.V316805.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were encouraged and supported to take part in the community life and to become part of it. They enjoyed the existing connections and felt independent and respected. EVIDENCE: All service users had different daily routines that fitted together when they were in the home. One attended college (her contract with the college was in picture format and signed), the other was doing voluntary work, one was using a computer, another attended a day centre… A variety of activities fitted together once they returned home: cooking for all, making cakes, cleaning, dusting… all house tasks were shared amongst the service users who were supported by staff. Creek Road (79) DS0000015296.V316805.R01.S.doc Version 5.2 Page 13 A service user presented her work uniform to the inspector. A college certificate of one user was displayed in the home. Service users commented how there was not much happening in the small village community and they relied on bigger events in Peterborough. However, they used local library service and other available community resources. They also commented on their relationship to their neighbours showing that they felt a part of the community. There was some difficulty in ensuring regular weekend outings, as only one member of staff worked for weekends, unless some main event was planned for an individual or the whole group. Service users were also going away to relatives or friends for weekends and this was an additional factor that needed to be taken into account when weekend activities were planned. Weekend shifts were identified by service users as potentially benefiting from an additional staff member. Hobbies and interests were encouraged and consequently a user used a computer and another explained daily life: “We cook tea here, we do housework, have parties, watch TV or play cards.” Staff were observed interacting with service users and the small size of the home brought benefits to service users of having more time with the staff on duty. Users were free to form relationships and boyfriends were a favourite topic of discussion for the girls. They went on holiday in pairs, taking into account their likes and dislikes, in this case hotter or milder weather. The users stressed that the home offered the opportunity to pursue their leisure interests above the standard requirements. Mealtimes were not strictly set and were more based around the arrangement service users agreed to on each day. A mealtime was observed and looked very relaxed and friendly. Users chose the food they liked and they cooked with staff’s support. Service users decided at their meetings about the shopping list according to their choice of food for each week. Creek Road (79) DS0000015296.V316805.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20,21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were supported to maintain their personal health needs and appropriate records were kept in the home. These included appropriate medication records. EVIDENCE: Service users were quite independent and the support by staff was provided in the way they wanted. A service user was cooking a meal at the time of the second visit. A staff member was observed helping her cook, helping another user lay the table and supporting the user who was unwell at that time. The records demonstrated that staff managed to support users how they wanted. Two of them confirmed that they could get up when they wanted, apart from when they had the responsibility to attend day activities: a day centre and voluntary work. Staff also advised a user on how to do her laundry and keep her personal appearance presentable. As all service users were females, two female staff was an appropriate balance. Additional support from specific professionals was provided through the day Creek Road (79) DS0000015296.V316805.R01.S.doc Version 5.2 Page 15 centre. Service users were able to attend an opticians’ in the community and were supported by staff to keep that aspect of independence. A service user explained how she was getting support to access her GP when it was necessary. Medication was securely stored in the home and a service user stated: “I prefer staff to keep my medication.” Another user was collecting her own medication from the pharmacy. Medication administration records were appropriate. Staff received medication training through Boots. Transferring the balance of the small stock of medication was discussed during the site visit and staff started straight away with recording the total amount of medication held in the home. A risk assessment for self-medicating service user was written and signed. Service users’ records contained information of users wishes in case of death and funeral arrangements. Creek Road (79) DS0000015296.V316805.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were protected by the effective management of behaviour in the home and by appropriate records. They were fully aware of the complaint procedure, but there were no complaints. EVIDENCE: The home had a record book of complaints, but there were no entries as there were no complaints. Service users were clear of the complaint procedure. The procedure was displayed in the porch and had a set time scale and path of investigation explained. Service users were protected from abuse not only with good working practices, but also with appropriate risk assessments and other records. Users were educated in the home to show respect to each other and to avoid any abusive behaviour. Some of them wanted the home to keep small amounts of their money, but were fully aware of balances and records that were appropriate. All service users were signing their money records. Creek Road (79) DS0000015296.V316805.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The poor rating was determined by the home not having responded to requirements set several times before. The dangerous sealant on a cooker was also not addressed appropriately. Service users deserved better accommodation conditions. EVIDENCE: The comfortable house was what service users wanted and they felt at home. Two of them stated how much nicer was to live here than in a bigger project where they had moved from. However, the old carpet in a lounge was not replaced despite repeated requirements from the previous inspections. The staff’s computer was located in a dining room and affected the homely style. The filing cabinets were also kept there which also did not help create a homely environment. Creek Road (79) DS0000015296.V316805.R01.S.doc Version 5.2 Page 18 The metal sealant of the ring on an old cooker was broken, making it difficult to clean and potentially dangerous for service users. The cooker needed replacement. The kitchen ceiling was decorated, sofas’ were replaced and the maintenance man recruitment was almost completed, as the home’s response to previous requirements. The employment of this person on a part time basis should ensure an on-going maintenance programme. Service users knew food hygiene rules for keeping food in the fridge and even pointed out to staff if they noticed a wrong storing of an ingredient on a wrong shelf. The home was clean and users were proud to state that they were responsible for keeping it nice and clean. Users were using a laundry room with staff supervision. Two service users rooms shown to the inspector were personalised and users were proud to state that they kept their rooms clean and tidy. Creek Road (79) DS0000015296.V316805.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The staffing level needed to be reviewed and a clear picture of care hours needed to be devised to evidence that two existing staff were able to meet the needs of service users and fulfil the other requirements of the home within their contracted hours. EVIDENCE: Staff members were clear of their responsibilities. They were very close to service users and knew them extremely well. Both staff were aware of their own limitations. Both staff were trained and, obviously, with holding NVQ, exceeded this standard by achieving 100 of NVQ trained staff. The support worker wanted to further improve and to start NVQ 3. All mandatory training was up to date for both. Although users’ needs were met in conditions were they were encouraged to use their own initiative and independence, the users themselves stated that another staff member was necessary. Having just one care staff on duty each shift created some limits in how to accommodate outings or provide different Creek Road (79) DS0000015296.V316805.R01.S.doc Version 5.2 Page 20 out from house activities. The management aspects of the home were mainly addressed in the manager’s own time. The calculation of the necessary staffing number from the Guidance of Department of Health indicated 2.58 staff. (The formula related to care hours and did not consider a situation whereby a care staff member was the manager too and combined the care and management hours). In addition, the principle to have a manager as supernumery, as required by the Care Standards Act, could not be effectively implemented in such a small home. So, in reaching a judgement of staffing number, the outcome and wishes of service users were the main factor to determine that at least a part time member of care staff was needed. One user described the need as “fair” and explained: “…to allow our staff to have the rest and proper time off”. The provider must seriously review the staffing number in relation to care hours required, as the existing two staff were responsible for management, cleaning, washing and even for maintaining the garden. This was addressed on the previous inspection, but no further action was taken and the evidence of meeting the needs of users and completing the other requirements of a daily life in the home showed that only flexibility and willingness of staff to cover for each other at any time, to respond to potential emergencies at any time and to rely on a visitor to help them with gardening, was not as effective as it was assumed. The home did not have a written rota, as two staff knew their working days and could clearly communicate who worked when, so that service users were aware of how the shifts were covered. Although the written rota was not necessary in current conditions, it could potentially demonstrate how the management hours in the home worked. Recruitment of these two staff was carried out appropriately. The current recruitment of a part time handyman showed that recruitment was appropriately conducted. Staff were trained in all mandatory subjects. Being flexible and supportive to each other created the opportunity for training. As the communication between these two staff was effective, the support and supervision was appropriate. Creek Road (79) DS0000015296.V316805.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home operated safely and trained service users in some safety procedures, allowing them to keep responsibility for themselves. EVIDENCE: The manager was experienced and skilled. She had filled in an application for registration and was awaiting her CRB, Criminal Record disclosure in order to progress with the registration process. She was responsible only for this project and was providing out of hours on-call cover. She was also working all her hours as a direct care worker, covering other duties, such as cleaning, maintenance, cooking and washing and management, trying to fit all these duties into her contracted hours. She stated that she needed to use some of her time off to complete all management duties related to the home. Creek Road (79) DS0000015296.V316805.R01.S.doc Version 5.2 Page 22 The home organised a survey with relatives as a part of their quality assurance, but the current survey did not include service users. The comments from service users were collected mainly through daily contacts and were not always recorded for the purpose of quality assurance review. The home operated safely and any potential risk was discussed with service users. The majority of the identified risks were addressed in risk assessments. The size of the project provided an opportunity to discuss and train service users in safety procedures, as had happened with fire procedure and food hygiene, that service users explained to the inspector during the site visit. A user pointed out how food should be stored in a fridge, according to food hygiene guidance. Creek Road (79) DS0000015296.V316805.R01.S.doc Version 5.2 Page 23 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 3 2 3 3 3 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 1 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 4 33 1 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 4 4 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 2 X X 3 X Creek Road (79) DS0000015296.V316805.R01.S.doc Version 5.2 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA24 Regulation 16(2)(c) Requirement The carpets referred to must be replaced with a suitable floor covering. Previous timescale 15/09/06 and 30/04/06 not met Timescale for action 30/12/06 2. YA24 16 2. YA33 18(1) (a) The cooker must be replaced as 30/12/06 the broken metal seal around rings presented a serious hazard to service users when they cleaned the cooker. The registered provider must 30/12/06 ensure that there are sufficient staff in the home to meet the stated purpose and needs of the service users. Previous time scale 21/02/06 not met. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA5 Good Practice Recommendations The contract should be signed by a service user or their representative and should contain a room number for each DS0000015296.V316805.R01.S.doc Version 5.2 Page 25 Creek Road (79) 2 3 YA33 YA39 individual accepted to that room. The home should have a written rota to demonstrate how the balance of care and management hours was constructed. The home should introduce an effective quality assurance system whereby service users and professionals visiting the home should be more formally consulted and these records used as a part of the quality assurance reviews. In this way the feedback and action plan devised from the comments could be systematic and present an effective quality assurance monitoring system. Creek Road (79) DS0000015296.V316805.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Creek Road (79) DS0000015296.V316805.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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