Inspection on 02/11/06 for Hazel Mead

This inspection was carried out on 2nd November 2006.

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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hazel Mead 27/06/07

Hazel Mead 09/05/06

Hazel Mead 06/09/05

Hazel Mead 28/04/05

Hazel Mead 15/12/04

Hazel Mead 18/06/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Hazel Mead 3 Elpha Court South Broomhill Morpeth Northumberland NE65 9RR Lead Inspector Elaine Charlton Key Unannounced Inspection 2 November 2006 12:40 nd Hazel Mead DS0000040943.V316985.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 Hazel Mead DS0000040943.V316985.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. Hazel Mead DS0000040943.V316985.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hazel Mead Address 3 Elpha Court South Broomhill Morpeth Northumberland NE65 9RR 01670 761 741 01670 761 351 elsie@elpha.totalserve.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Elsie Hazel Dixon Mrs Linda Marshall Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Hazel Mead DS0000040943.V316985.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th May 2006 Brief Description of the Service: Hazel Mead is in Broomhill village. The bungalow has five, single, en-suite bedrooms for younger adults with a learning disability. The home is built in the grounds of Elpha Lodge a care home for younger adults with physical disabilities. People who need to use a wheelchair can get around the bungalow and grounds easily. The decoration and furnishings are of a high standard. The home is close to local shops and bus routes. Service users can also use transport shared with Elpha Lodge. Respite care and nursing care are not provided. Service users who have been assessed as needing a service by a Care Manager are charged between £550 and £605 per week. The service users contract will show what the charges include. For example, furniture, bedding, soap, shampoo and door keys. Items that will need to be paid for separately could include newspapers, hairdressing, and clothes. People, who live in the home, or those who might wish to, can look at the service user guide. A copy of the latest inspection report is always available in the entrance hall of the home. Hazel Mead DS0000040943.V316985.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The registered manager was given late notice of this second inspection, which lasted for 4 hours. The reason for the inspection was to look at the requirements made at the last inspection to see if they had been met, and the key standards. Two service user files and one member of staff’s supervision records (with their permission) were seen. Other records looked at included training, complaints, compliments, quality assurance, menus and protection of vulnerable adults. The four service users who live at the home were spoken to during the afternoon. A new person is visiting the home to join service users for meals and overnight stays so that they can decide whether to move in. Two staff on duty were also spoken to. No questionnaires were sent out for this inspection. Two were received from professionals who visit the home following the last inspection. Their comments and those of the service users and staff are included in the report. What the service does well: The home is kept safe and comfortable for service users. Service users are asked how they want to spend their time. Service users are able to go out to work if they want. Service users live in a relaxed, flexible and inclusive environment. People who might want to live in the home are helped to make this decision in their own time. Service users receive care from a reliable team of staff who they know well. Service users share the task of choosing what they are going to eat. Promotes the involvement of health care professionals to support service users with their health care and emotional needs. One health care professional said: “They were able to see service users in private. Staff understand service users needs and communicate clearly. Medication is appropriately Hazel Mead DS0000040943.V316985.R01.S.doc Version 5.2 Page 6 managed. No complaints had been received. Could see copies of the inspection reports.” What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Hazel Mead DS0000040943.V316985.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 Hazel Mead DS0000040943.V316985.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 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in or visit the home are given information to help them make choices. The needs and wishes of service users are assessed. Service users have contracts. EVIDENCE: The service user guide is written in a way that is easily understood. Everyone has a copy of the guide and the complaints procedure in their bedroom. The registered manager is trying to provide an audio copy of the service user guide and complaints procedure. A full assessment of the needs of someone who might want to come to live in the home had been received. This was of a good standard. There was also a Hazel Mead DS0000040943.V316985.R01.S.doc Version 5.2 Page 9 letter from the occupational therapist setting out equipment that would need to be fitted or obtained. People who might want to come to live in the home are given a questionnaire to complete, sometimes with the help of their family, about their health care needs and doctors details. The person who may want to move into the home is being helped by the registered manager to visit the home as often as they wish and to decide about the move at their own pace. This is very good practice. Service users each have a contract with the home. The registered manager is updating this to include details of what is included in the homes fees. For example, furniture, bedding, soap, shampoo, door keys, and what the service user can expect to pay for. This would include more personal items like newspapers, hairdressing and clothing. Hazel Mead DS0000040943.V316985.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 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users sign their care plans to show that they have been involved and know what has been said. Service users can make choices about their daily lives and this is recorded in their care plans. Risk assessments are carried out and support service users to be independent and safe. EVIDENCE: Two service users who were at home throughout the inspection were heard and seen making choices about when they wanted a drink, whether they wanted to go out and what they wanted to spend their time doing. Hazel Mead DS0000040943.V316985.R01.S.doc Version 5.2 Page 11 Two other service users returned home during the inspection. One had been to college and the other to a service user forum. Both service users are able to travel independently as well as by using the home’s transport. A service user who said at the last inspection they would like to be able to spend more 1-1 time with the key worker has been able to do this. The key worker said that it was nice to have more freedom in 1-1’s, and not to feel pressured to return to the home at a set time should a service user decide they want to do something else. Service users sign their care plans and choose the colour of file that they want their records to be kept in. Care plans showed the activity being carried out and other care plans and risk assessments that might need to be looked at. This is good practice. The records seen were very personal and sensitive. One service user had had several visits from a health care professional to help them understand relationships and the differences between relatives, girlfriends, and boyfriends. The monthly evaluations of care plans show how service users have benefited from the support they receive, what they have achieved and how they felt doing different things. This is very good practice. Everyone has a person centred plan. Two are complete and work on the other two is still taking place. Hazel Mead DS0000040943.V316985.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, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are encouraged to take part in educational, employment and social opportunities to increase their independence. Service users visit, and have visits from, friends and family promoting their involvement in the community and to continue to be part of their family. Service users are respected and make choices about their daily lives. Service users plan the home’s menus and meal times are flexible and relaxed. Hazel Mead DS0000040943.V316985.R01.S.doc Version 5.2 Page 13 EVIDENCE: Service users told the inspector about their holidays and Halloween parties they had been to. Everyone has had two holidays this year (Silloth and Blackpool). Even though the holidays were communal, staffing levels meant that each service user could spend their holiday doing the things they wanted to. Two service users are still attending college courses. One person goes out to work four days a week. Two service users are able to travel independently as well as use the home’s minibus or car. Plans have been made for two Christmas parties. One will be at the local pub where Hazel Mead service users will join their friends from Elpha Lodge. One service user said they had already started their Christmas shopping. Spiral Skills hold regular service user forums and one person from the home attends these. Service users sit down together on Sundays to choose the menu for the next week. Everyone chooses the meal for one day and then take it in turn to choose the Sunday roast. One service user said they could have a full cooked breakfast if they wanted but usually only had this at the weekend. Menus are imaginative, varied and promote health eating. A member of staff said the service users liked to try new recipes. Service users can make snacks and drinks when they want. The kitchen is domestic in style and contains modern appliances. Separate chopping boards are used for meat and vegetables, and the area is kept extremely clean. A separate basin for hand washing is also provided. Service users share shopping tasks, enjoy meals out in the local community and join in with social activities (bowling is an example) where they wish. One service user who has preferred to stay at home was heard being asked if they would like to go out. Twice during the inspection they took short walks. Hazel Mead DS0000040943.V316985.R01.S.doc Version 5.2 Page 14 Daily routines are very flexible and are only limited by service users attendance at college or work. Hazel Mead DS0000040943.V316985.R01.S.doc Version 5.2 Page 15 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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users choose how they want to receive personal care, and who from. Staff work closely with health care professionals to support service users physical and emotional needs. Service users health and safety is promoted through policies, procedures and training in the safe handling of medication. EVIDENCE: Each bedroom has an en-suite facility, which includes a toilet, shower and wash hand basin. Service users are supported with their personal care needs in a private and sensitive way. A female member of staff is always available to help female service users with their personal care needs. Hazel Mead DS0000040943.V316985.R01.S.doc Version 5.2 Page 16 New monitor sheets for each service user have been set up and staff record on these visits from the GP, nurse, optician, chiropodist, dentist or other health care professional. Each service user had had visits from one or a number of these professionals. Service users weights are recorded regularly as part of the healthy living programme. A random check of medications held in the home was carried out. Records seen were up to date and complete. No errors were identified. Two service users are able to self-administer prescribed creams, and one service user manages oxygen therapy independently. Record sheets and medication are kept in a locked cupboard. A separate cabinet and register are available for the safe keeping of controlled drugs. There are no controlled drugs being used at the moment. Staff have all received training in the safe handling of medication. Recordings and letters seen showed that the support, advice and input of a range of health care professionals is sought as and when service users needs dictate. Hazel Mead DS0000040943.V316985.R01.S.doc Version 5.2 Page 17 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 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users know they are listened to and their views are acted upon. Policies, procedures and staff training protect service users from abuse, neglect or self-harm. EVIDENCE: Policies and procedures are in place to help service users and staff make, record and investigate complaints, concerns or disclosures. All staff have had training in the Protection of Vulnerable Adults (POVA). A paragraph on page 2 of the home’s POVA guidance needs to be re-worded. The statement about not referring an issue to an appropriate agency if a service user did not wish should include the circumstances for such a decision being made. A complaints file and a POVA file have been set up as a single source of information and guidance for staff. Service users have a copy of an easy to understand complaints procedure. Hazel Mead DS0000040943.V316985.R01.S.doc Version 5.2 Page 18 Complaints and concerns are a regular item on the agenda for service users meetings. Service users also join in staff meetings. One of the homes procedures or policies is discussed at each meeting. A copy of the most recent inspection report is always available in the hallway of the home. Guidance for staff also included advice on dealing with service users who may purchase or access pornography, want to get married, need help with their sexual awareness, relationships, and consent. This advice was very detailed. Hazel Mead DS0000040943.V316985.R01.S.doc Version 5.2 Page 19 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 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users live in a comfortable, homely and secure environment. The home is kept in a very clean and hygienic way. EVIDENCE: Service users have their own bedroom and bathroom. Bathrooms are fitted with a toilet, wash hand basin and shower. Where necessary aids have been fitted to help service users carry out their personal hygiene routines safely. A separate communal toilet is also provided. Furnishings in the home are of a high standard. When these need replacing, new furnishings are of an equally high quality. Hazel Mead DS0000040943.V316985.R01.S.doc Version 5.2 Page 20 Service users are encouraged and helped to personalise their bedrooms. This includes the installation of televisions, videos, computers, music keyboards, pictures and/or photographs. One service user gets great pleasure from cleaning their bedroom. Staff help if anything needs to be moved. This service user had recently asked to have their bedroom redecorated and was in the process of choosing colours. The hallway of the home had been redecorated. All areas of the home are light, airy and clean. All bedroom doors are fitted with locks and service users choose whether or not they wish to have a key. Two service users who are often out have keys and one always keeps his room locked. Staff have good, shared routines for maintaining high levels of cleanliness. Service users and staff use the laundry at Elpha Lodge. This can cause a problem if only one member of staff is on duty and the service user or users at home do not wish to help. The location does not make it easy for service users to do their own laundry. For the first time no laundry, ironing or ironing equipment was seen in the dining room. Cleaning products are kept safely within the home. Hazel Mead DS0000040943.V316985.R01.S.doc Version 5.2 Page 21 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): 32, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are protected by the home’s recruitment and selection procedures. Service users are supported by staff that are competent and trained. Staff receive regular supervision to support service users. EVIDENCE: No new staff have been recruited into the home. Recruitment and selection policies and procedures are in place. Training for the month of October included fire safety, health and safety and infection control. Hazel Mead DS0000040943.V316985.R01.S.doc Version 5.2 Page 22 The registered manager has set up a simple, in-house, evaluation form to gain feedback on training. This feedback will be used to decide whether the course should be repeated for other staff or whether alternatives should be considered. This is good practice. Monitor sheets have been set up to record the frequency of staff meetings, service user meetings, supervision/appraisal, fire instruction, questionnaires sent out/returned as part of the quality assurance process, and reviews. Service user and staff meetings had both been held in October. All staff had received supervision in October. One member of the staff team gave permission for the inspector to see their supervision notes. Staff have also signed a form, in line with Data Protection requirements, agreeing to private and confidential information about them being kept on the home’s computer. All staff have gained a National Vocational Qualification (NVQ) at a minimum of level 2. The registered manager has started her NVQ level 4 and registered managers award. Staff training needs are identified as part of supervision and appraisal. Planned training includes palliative care, health and safety, challenging behaviour, fire safety, moving and handling and epilepsy. One member of staff said the palliative care training was initially upsetting but very valuable. Staff spoke with confidence about service users needs, training and the new manager. Service user and staff relationships were seen to be appropriate and sensitive. Both were heard chatting freely and enjoying jokes whilst preparing meals and carrying out activities. Hazel Mead DS0000040943.V316985.R01.S.doc Version 5.2 Page 23 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 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well managed home. The results of quality assurance surveys are not well-reported and shared with service users or other interested parties. Service users health, safety and welfare is promoted through risk assessments and staff training. Hazel Mead DS0000040943.V316985.R01.S.doc Version 5.2 Page 24 EVIDENCE: One health care professional, who visits the home, returned a questionnaire after the last inspection report had been finished. They said they were able to see service users in private, that staff understand service users needs and communicate clearly. Medication was also appropriately managed. They had received no complaints and were able to see copies of the inspection reports. The registered manager has only one and a half units of her registered managers award still to complete. In-house COSHH (Control of Substances Hazardous to Health) guidance and risk assessments have all been updated. The registered manager got one of the staff team to help with this process. Before starting to update COSHH records the registered manager wrote to all the manufacturers of products used in the home to get their up to date safety sheets. A computer and printer have been installed in the home’s office. A review of all records kept in the home has been carried out and those that can be archived have been removed. This has made a big difference to the amount of paper and files in the office. It has also made it easier for everyone to find information and records. The registered manager and staff are using a simple, pictorial questionnaire to record service users views about the home, food, holidays, support and how much choice they get. Up to date insurance cover and the home’s certificate of registration are displayed in the hallway of the home. The Fire Officer has confirmed in writing that it is safe to site the oxygen storage cabinet at the side of the bungalow. The storage unit does not provide staff with cover whilst they are filling the oxygen units used for outings. The registered manager showed the inspector a basic policy on equality and diversity. This set out the home’s basic aims and encouragement of service users around tolerance and empowerment. Hazel Mead DS0000040943.V316985.R01.S.doc Version 5.2 Page 25 A recording system is being set up to register any restriction of rights and the reason for it. Hazel Mead DS0000040943.V316985.R01.S.doc Version 5.2 Page 26 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 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 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 2 X Hazel Mead DS0000040943.V316985.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA39 Regulation 24 Requirement The quality assurance system must be reviewed to ensure that it meets the requirements of Regulation 24. (Previous timescales of 18 July 2005, 30 March 2006, and 15 June 2006, partially met.) 2. YA42 13(4) The outside storage facility for oxygen must be reviewed for the safety and comfort of staff. 30/03/07 Timescale for action 15/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA1 YA23 Good Practice Recommendations Obtain an audio copy of the service user guide and complaints procedure. Review the wording of the POVA guidance referring to service user agreement. Hazel Mead DS0000040943.V316985.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Hazel Mead DS0000040943.V316985.R01.S.doc Version 5.2 Page 29 - 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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