Inspection on 18/10/05 for Grosvenor Terrace, 52-60

This inspection was carried out on 18th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Grosvenor Terrace, 52-60 16/02/09

Grosvenor Terrace, 52-60 05/02/08

Grosvenor Terrace, 52-60 18/12/06

Grosvenor Terrace, 52-60 18/05/06

Grosvenor Terrace, 52-60 02/06/05

Grosvenor Terrace, 52-60 11/11/04

Grosvenor Terrace, 52-60 23/08/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

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 Grosvenor Terrace, 52/60 52/60 Grosvenor Terrace Camberwell London SE5 0NP Lead Inspector Lisa Wilde Unannounced Inspection 18th October 2005 10:00 Grosvenor Terrace, 52/60 DS0000060236.V257481.R01.S.doc Version 5.0 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 Grosvenor Terrace, 52/60 DS0000060236.V257481.R01.S.doc Version 5.0 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. Grosvenor Terrace, 52/60 DS0000060236.V257481.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Grosvenor Terrace, 52/60 Address 52/60 Grosvenor Terrace Camberwell London SE5 0NP 020 7277 1619 020 7277 1619 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) Odyssey Care Solutions for Today Mr Oyedele Salami Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Grosvenor Terrace, 52/60 DS0000060236.V257481.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd June 2005 Brief Description of the Service: 52-60 Grosvenor Terrace is a home which can accommodate a maximum of eight adults with learning disabilities. It is located in a residential street just a short distance from the shopping area of Walworth Road. The home is made up of two large Victorian terraced houses that are connected with a garden and patio at the rear. There is a disabled parking bay outside the home that is used for the home’s minibus. On the ground floor are 2 bedrooms that are wheelchair accessible. No 60 has a specially adapted kitchen for wheelchair users. The home is situated close to local shops, entertainment and public amenities. There is no lift in the home. There were no vacancies at the time of this inspection and all the current service users have been at the home for a number of years. The vision statement of Odyssey is an aspiration to: “A society where a learning disability is not a barrier to somebody’s perceived value or ability to make a meaningful contribution.” Grosvenor Terrace, 52/60 DS0000060236.V257481.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day in October 2005. The Registered Manager was on training on the day but was telephoned by the inspector after the inspection. Most of the service users at this home are non-verbal so it was difficult for the inspector to find out what they thought of the home. One service user said they were very happy and enjoyed living at the home. The inspector attempted to contact family members following the inspection but only made contact with one who said that they were happy with the service and had no problems. The inspector found that there had been significant improvement since the last inspection, in the way the staff worked individually with service users to meet personal goals. There are still problems with the physical environment, particularly the bathrooms in the home and there were a number of unmet requirements from the previous inspections that must be achieved by the next inspection. What the service does well: What has improved since the last inspection? Considerable work has gone into how staff work with service users to develop skills and meet identified goals. The staff team is now offering a more person Grosvenor Terrace, 52/60 DS0000060236.V257481.R01.S.doc Version 5.0 Page 6 centred approach to the work and service users are benefiting by undertaking more personalised and useful tasks and activities. 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. Grosvenor Terrace, 52/60 DS0000060236.V257481.R01.S.doc Version 5.0 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 Grosvenor Terrace, 52/60 DS0000060236.V257481.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 5 The Service User Guide is not in a language or form that could be understood by the service user group at this home and it does not include some of the areas required by the standard meaning that service users and their families are not provided with all the information they need to make an informed choice about where to live and whether they are being offered everything that they should be. There have been no admissions to this home for many years so the current procedures for assessing prospective service users’ aspirations and needs have not been used recently. There is no reason to believe that the home would not fully assess a prospective service user’s needs prior to making the decision whether to accept them into the home. As the current service user contracts have not been agreed by the service users or their representatives the home cannot show that service users or people acting on their behalf have agreed to the terms and conditions of the placements. EVIDENCE: There was a previous requirement that the Service User Guide must be drawn up in a format that can be understood by more people from the service user groups for which the home is registered i.e learning disabilities and the Service User Guide must cover all areas required by Regulation 5 and Standard 1. This Grosvenor Terrace, 52/60 DS0000060236.V257481.R01.S.doc Version 5.0 Page 9 work hadnot yet been don and the requirements are repeated (See Requirements 1 & 2) All the current service users have been at this home for a long time and as there have been no admissions there has been no need for pre-admission assessments. The files showed that full assessments of current needs take place and are reviewed at least annually. Discussions with staff evidenced that they have knowledge of service users needs and how to meet them as a team. There was a previous requirement that service user contracts must be signed by the service user or their representative e.g. family member of advocate and dated. Some of the contracts had been signed but some had not and the requirement is repeated. (See Requirement 3) Grosvenor Terrace, 52/60 DS0000060236.V257481.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 The staff team has now begun to establish goals for service users and develop programmes of support that enable them to develop skills and achieve greater independence. As far as possible service users are included in decisions about their lives. Given the communication limits of the service users at this home, family members and independent advocates are included in the decision making process. Risks are assessed effectively and plans put in place to manage or minimise those risks. EVIDENCE: There was a previous requirement that service User plans must focus on forward planning and how staff will support service users to achieve identified goals, develop positive behaviour and minimise negative or challenging behaviour and maximise independence. These plans must be reviewed at regular intervals to allow for plans to be changed if they are not working to ensure (as far as possible) that goals are met by the time the next six monthly mutli disciplinary review takes place. The deputy manager stated that the Grosvenor Terrace, 52/60 DS0000060236.V257481.R01.S.doc Version 5.0 Page 11 process for setting goals eand working towards them has changed since staff have all attned person centred planning training. The inspector sat in in the staff meeting where this new process was discussed and found that staff are now working with service users to establish short term goals that are reviewed every quarter. These goals are focussing on developing tasks and skills and undertaking activities. This new work must now be incorporated into the service user care plans. (See Requirement 4) The service users at this home are non-verbal and have limited communication abilities. Staff hold knowledge of the service users, as they have known them for many years. The talked about how they are able to understand the behaviour of the service users and assess their moods and wishes as far as possible. The home access independent advocates for service users in their reviews and family are involved as much as possible. Risk assessments were on file for service users with actions to be taken to manage or minimise identified risks. Grosvenor Terrace, 52/60 DS0000060236.V257481.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 & 17 Generally service users are supported to access the community and undertake a varied and appropriate activities programme throughout the week. The fact that the home has not currently got its own transport means that there are problems enabling service users to get out of the home as they choose. Service users are offered a healthy diet and as far as is possible to judge, they enjoy their food. EVIDENCE: Discussion with staff and evidence from the weekly programmes in the files show that service users are supported to access the local community and undertake activities outside of the home. The home is currently having problems with transport as the van that they use is out of use. Staff said it is difficult to enable service users to attend the activities they choose without the home’s transport. On the day of the inspection one service user was stuck at the day centre as a taxi could not be accessed on time (See Requirement 5) Grosvenor Terrace, 52/60 DS0000060236.V257481.R01.S.doc Version 5.0 Page 13 The menus showed that service users being offered a healthy, varied diet. One service user said they enjoyed their food. As most of the service users are non-verbal it is more difficult to assess what they want but staff said that they show service users different options and enable them to make certain choices. Grosvenor Terrace, 52/60 DS0000060236.V257481.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 The home is protecting service users by the operation of effective medication storage and administration systems. EVIDENCE: The inspector checked the stocks of medication held in the home and the administration records. There were no problems found with the systems that are being operated. There were no photos of service users held on the medication files (See Requirement 6). The community pharmacist attends the home to train staff. Grosvenor Terrace, 52/60 DS0000060236.V257481.R01.S.doc Version 5.0 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 Complaints are recorded and taken seriously. Action is taken as a result if complaints investigations. Information in the current complaints procedure about where service users and their families can complain outside of the home is not correct, meaning that service users’ families are not being given useful information about what they can do if they have a problem but don’t want to talk to staff at the home. EVIDENCE: There was a previous requirement that aall complaints must be recorded in the complaints book with evidence of action taken, timescales and whether the complainant was happy with the outcome. Evidence from the book showed that this is now being done. The inspector discussed one complaint that had been investigated since the last inspection and found that it had been taken seriously and staff had been offered additional training and input as a result. There was a previous requirement that the Complaints Procedure must be updated to include current contact details of the Commission and a brief explanation of what the Commission do so that people understand why they may need to complain directly to them. This had not been done and the previous requirement is repeated. (See Requirement 7) Grosvenor Terrace, 52/60 DS0000060236.V257481.R01.S.doc Version 5.0 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 & 30 Generally the home is comfortable and safe although the bathrooms, one upstairs in particular, are institutional rather than homely which isn’t the best physical environment for these long-term service users. The home isn’t currently able to make day-to-day repairs quickly enough to maintain the home adequately and safely. The bedrooms, bathrooms and other shared spaces in the home all meet the size requirements of the standards and are adapted appropriately to maximise the independence for wheelchair users. Checks take place to ensure the ongoing effectiveness of any adaptations and fittings. The home is clean, hygienic and free from odours. EVIDENCE: There was a previous requirement that work must be done on all the bathrooms and toilets, particulary the upstairs bathrrom in No 60, to ensure they are homely rather than institutional with regard to decoration and fittings. This work had not been done and in addition one of the bathrooms is out of use meaning that there is only one bathroom for six service users, one service user having their own ensuite room and another using the shower room. (See Requirements 8 & 9) Grosvenor Terrace, 52/60 DS0000060236.V257481.R01.S.doc Version 5.0 Page 17 There was a previous requirement that the Registered Provider must supply a copy of any further planned maintenance and renewal for the fabric and decoration of the premises to the C.S.C.I. which has not been done and is repeated. (See Requirement 10 ) There was a previous requirement that the organisation must ensure that the home is issued with clear guidance about who is responsible for repairs and maintenance in the home and that all necessary repairs are carried out in a timely manner. Staff stated that this is still an ongoing issue and the previous requirement is repeated (See Requirement 11) All bedrooms in the home are single and meet the size requirements of the standards. The home has two good-sized lounges that are have comfortable furniture and are spacious enough to accommodate wheelchair users. There is a large activities room that is used for group activities and stores a variety of equipment used in activity sessions. The two dining rooms are situated off both kitchens with adequate seating provided for service users in each house. On the day of the inspection the home was clean and free from offensive odours. The home has appropriate health and safety policies and procedures for the control of infection. The home has appropriate laundry facilities. Grosvenor Terrace, 52/60 DS0000060236.V257481.R01.S.doc Version 5.0 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 The number of permanent staff vacancies and the NVQ levels the home is not currently ensuring that its staff are as effective as possible which means that service users are not benefiting from a consistent and fully qualified team. EVIDENCE: There are currently five staff vacancies that the deputy manager stated are being filled by bank staff. (See Requirement 12) The home is not currently meeting the target of 50 of care being delivered by staff who hold the NVQ Level 2 in Care or equivalent (See Requirement 13) The inspector will be assessing the recruitment records for the entire organisation at its head office at a later date in the year. Grosvenor Terrace, 52/60 DS0000060236.V257481.R01.S.doc Version 5.0 Page 19 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): 39 & 42 Although the organisation does undertake reviews of care and includes the goals of service users in their development plans for the home, the home does not ensure that service users’ views (or the views of their families) underpin the review and development of the home. The health, safety and welfare of service users are being protected by the effective use of procedures and regular monitoring at the home. EVIDENCE: Throughout the tour of the home and inspection of all checks, certificates and health and safety monitoring it was shown that the home is ensuring as far as possible the health and welfare of the service users. There was a previous requirement that the home must develop an annual development plan that reflect aims and outcomes for service users. Views of family, friends, advocates and other stakeholders (e.g. G.Ps, local community) must be sought annually to feed into this development plan. From inspections of other Odyssey homes the inspector had been made aware that the Grosvenor Terrace, 52/60 DS0000060236.V257481.R01.S.doc Version 5.0 Page 20 organisation is currently planning an organisational procedure for gathering the views of families and other parties. (See Requirement 14 and Recommendation 1) There was a previous requirement that refresher training must be offered to staff in the areas of Food Hygiene and Fire Safety. Training records showed that this work has started but as yet all staff have not undergone the refresher training (See Requirement 15) Grosvenor Terrace, 52/60 DS0000060236.V257481.R01.S.doc Version 5.0 Page 21 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 X X 2 Standard No 22 23 Score 2 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 2 3 X 3 LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 X X X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Grosvenor Terrace, 52/60 Score X X 3 X Standard No 37 38 39 40 41 42 43 Score X X 2 X X 3 X DS0000060236.V257481.R01.S.doc Version 5.0 Page 22 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 YA1 Regulation 5 Requirement The Registered Individuals must ensure that the Service User Guide must be drawn up in a format that can be understood by more people from the service user groups for which the home is registered i.e learning disabilities. Previous requirement: Unmet timescale 14/10/05 The Registered Individuals must ensure that the Service User Guide must cover all areas required by Regulation 5 and Standard 1. Previous requirement: Unmet timescale 14/10/05 The Registered Manager must ensure that service user contracts must be signed by the service user or their representative e.g. family member of advocate and dated. Previous requirement: Unmet timescale 30/09/05 The Registered Manager must ensure that the new care planning and goal setting systems in operation are incorporated into the care plan DS0000060236.V257481.R01.S.doc Timescale for action 31/01/06 2 YA1 5 31/01/06 3 YA5 5 (3) 31/01/06 4 YA6 15 31/01/06 Grosvenor Terrace, 52/60 Version 5.0 Page 23 documents. 5 YA13 16 (2) (m) & (n) The Registered Individual must ensure that the home’s transport is repaired or that effective alternatives are accessed in the interim. The Registered Manager must ensure that photos of service users are held in the medication files. The Registered Individuals must ensure that the Complaints Procedure must be updated to include current contact details of the Commission and a brief explanation of what the Commission do so that people understand why they may need to complain directly to them. Previous requirement: Unmet timescale 31/07/05 The Registered Individuals must ensure that work must be done on all the bathrooms and toilets, particulary the upstairs bathrrom in No 60, to ensure they are homely rather than institutional with regard to decoration and fittings. Previous requirement: Unmet timescale 30/09/05 The Registered Individual must ensure that the first floor bathroom is made operational. The Registered Provider must supply a copy of any further planned maintenance and renewal for the fabric and decoration of the premises to the C.S.C.I. which has not been done and is repeated. Previous requirement: Unmet timescales 31/08/04 & 31/08/05 The Registered Individual must ensure that the home is issued with clear guidance about who is responsible for repairs and maintenance in the home and that all necessary repairs are DS0000060236.V257481.R01.S.doc 30/11/05 6 YA20 13 (2) 30/11/05 7 YA22 22 31/01/06 8 YA27YA24 23 (2) (b) & (d) 31/12/05 9 10 YA27YA24 YA24 23 (2) (b) & (d) 23 (2) (b) 31/12/05 31/01/06 11 YA24 23 (2) (b) & (d) 31/01/06 Grosvenor Terrace, 52/60 Version 5.0 Page 24 12 YA32 18 (1) (a) 13 YA32 18 (1) (c) (i) 14 YA39 24 15 YA42 18 (1) (c) (i) carried out in a timely manner. Previous requirement: Unmet timescale 31/08/05 The Registered Individuals must ensure that the current staff vacancies are recruited to as a priority. The Registered Individuals must ensure that the home meets the required target if 50 of care being provided by staff holding the NVQ Level 2 in Care or equivalent. The Registered Individuals must ensure that the home must develop an annual development plan that reflect aims and outcomes for service users. Views of family, friends, advocates and other stakeholders (e.g. G.Ps, local community) must be sought annually to feed into this development plan. Previous requirement: Unmet timescale 31/10/05 The Registered Individuals must ensure that refresher training must be offered to staff in the areas of Food Hygiene and Fire Safety. Previous requirement: Unmet timescale 31/10/05 28/02/06 31/12/05 31/03/06 31/01/06 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 Refer to Standard YA39 Good Practice Recommendations The Responsible Individuals should consider investigating and employing a professionally recognised quality assurance tool within the home. Grosvenor Terrace, 52/60 DS0000060236.V257481.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 Grosvenor Terrace, 52/60 DS0000060236.V257481.R01.S.doc Version 5.0 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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