Inspection on 16/02/09 for Hollygrove

This inspection was carried out on 16th February 2009.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hollygrove 04/02/08

Hollygrove 12/10/06

Hollygrove 20/12/05

Hollygrove 01/08/05

Hollygrove 29/03/05

Hollygrove 15/07/04

Hollygrove 08/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2010.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Hollygrove 49 Roman Road Salisbury Wiltshire SP2 9BJ Two star good service The quality rating for this care home is: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Lynne Bennett Date: 1 7 0 2 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area Outcome area (for example: Choice of home) These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Internet address www.csci.org.uk Information about the care home Name of care home: Address: Hollygrove 49 Roman Road Salisbury Wiltshire SP2 9BJ 01722415578 01722415578 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Turning Point Limited care home 9 Number of places (if applicable): Under 65 Over 65 7 2 learning disability Additional conditions: No more than 7 service users with a Learning Disability at any one time No more than 2 service users with a Learning Disability, over 65 years of age at any one time. Date of last inspection 0 4 0 2 2 0 0 8 A bit about the care home Hollygrove provides care and accommodation for nine people with a learning disability, the majority of whom have a range of personal and communication needs. The property is situated in a residential area of the city, a short drive or bus ride from the centre. Hollygrove is a twostorey building, with peoples bedrooms on both floors. All bedrooms are single, have wash hand basins fitted and are close to toilets and bathrooms. Staffing levels are three staff during the waking day with one waking night staff and one staff sleeping in. Details of weekly fees can be obtained directly from the home. Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: Two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home How we did our inspection: This is what the inspector did when they were at the care home This inspection took place in February 2009 and included two visits to the home on 16th and 17th January 2009. The registered manager was not present during the visits. The registered manager completed an AQAA (Annual Quality Assurance Assessment) as part of the inspection, providing considerable information about the service and plans for further improvement. It also provided numerical information about the service (DataSet). All people living in the home were met and time was spent observing the care they received. Five members of staff were spoken with. We observed three people using the service, and asked staff about those peoples needs. We also looked at the care plans, medical records and daily notes for these three people. This is called case tracking. We had a walk around the home and looked at a variety of records including staff files, health and safety systems, quality assurance audits and medication records. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the care home does well A person centred approach to care is in place enabling people to be involved in planning how they wish to spend their lives. Excellent use is made of photographs and pictures around the home and in records to illustrate peoples aspirations and wishes and their lifestyles. People were observed being supported to go to day centres, go shopping and to the cinema and have reflexology. They appeared to have positive relationships with the staff supporting them. People were involved in the daily running of the home, helping with small tasks such as clearing the table or making a drink. They have freshly produced meals which they are beginning to help choose, shop for and prepare. The staff team are experienced and knowledgeable about the needs of people living in the home and have access to a robust training programme. What has got better from the last inspection The kitchen had been refurbished with good quality fixtures and fittings. Other environmental issues are in hand having been identified with the housing association for repair. People are not paying for staff expenses when they go out for a meal. Staffing levels are appropriate to the needs of people currently living at the home. What the care home could do better The registered person needs to make sure that unannounced visits to the home take place each month. This is outstanding from the last inspection. An annual report must be produced to reflect the outcomes of the quality assurance system. The temperature of the medication cabinet should be monitored. If you want to read the full report of our inspection please ask the person in charge of the care home If you want to speak to the inspector please contact Lynne Bennett Colston 33 Bristol BS1 4UA 0117 930 7110 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line - 0870 240 7535 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . People have access to the information they need enabling them to make a decision about whether they wish to live at the home. Ongoing re-assessment of people will ensure that the service is continuing to meet their changing needs. Evidence: The home had a Statement of Purpose and Service User Guide which had been produced in a format using text, symbol and photographs. Photographs in the Service User Guide were individualised to the person, showing their room and the activities they would be participating in. Copies of both documents were displayed in the entrance hall. There had been no new people admitted to the service. One person had moved to a spare room on the ground floor in response to their changing mobility needs. Staff confirmed that people were being invited to look around the home with a view to moving into the room on the first floor. Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . People are being involved in developing their care plans that reflect their aspirations and needs. Imaginative use of resources enables people to express their wishes and needs. Risks are being managed safeguarding them from possible harm. Evidence: The care of three people was case tracked and care plans for other people were sampled. Peoples care was being reviewed annually by the placing authority and involving other people important to them. Copies of the placement authority’s assessment of need and care plan were in place. From these individual person centred profiles and care plans had been developed. The profiles involved the use of photographs of each person showing how they like to spend their time and the support they need. These were kept in their rooms. Their care plans provided a holistic analysis of their identified physical, intellectual, social and emotional needs. Care plans were clear and succinct providing staff with the information they need to support people. Observations of staff during the visits confirmed their understanding of peoples care needs. There was some inconsistency in the records in place with most being reviewed at least every six months. Staff thought that one file had not been reviewed as frequently as others because the key worker was on long term absence. Arrangements should be put in place to make sure that when key members of staff are absent care planning documents should be monitored and reviewed. Daily records were being completed providing a summary of what people had done each day. Guidelines for one person to support them with their anxieties appeared to contradict a Evidence: management strategy which was on their file. Staff said that a new management strategy had been developed which was with staff for consultation. This was seen and staff said the former document would be archived. Communication care plans were in place providing an outline of peoples preferred form of communication such as makaton sign language, use of objects of reference or photographs. There was evidence that communication passports were in place detailing how to interpret peoples non verbal behaviour. There was excellent use of photographs around the home to illustrate activity boards, meals and which staff were on duty. Other records had also being developed using photographs such as the Service User Guide, a service user Involvement File - Work, Rest and Play and the complaints procedure. Staff were observed using makaton sign language and objects of reference during the visits. There was information around the home about local advocacy networks and staff confirmed that where appropriate the services of an Independent Mental Capacity Advocate would be provided. There were no restrictions in place in the home. Peoples finances were managed through a corporate account and people had access to their money through the petty cash system. Records were being maintained for all expenditure and receipts obtained. Any expenditure over a set amount needed the permission of the registered manager. There was no evidence in the home of what each person had in their current balance and whether or not they had accrued interest. Each person had a baseline risk assessment checklist which identified hazards from which individual core and specific risk assessments had been developed. These covered hazards faced from mobility, abuse, fire, finances, bathing and self harm. Risk assessments were individual and specific to the person concerned providing staff with clear guidance about how to reduce risks. Staff spoken with had a good understanding of these documents. Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . People who live at the home make choices about their lifestyle, and are supported to develop life skills. They have the opportunity to take part in social, educational and recreational activities and keep in touch with family and friends. People have a nutritional diet and their diverse needs are catered for. Evidence: People were accessing a range of activities at several different day centres. An activity board in the kitchen provided information about what people were doing each day, using photographs and pictures. One person also had their own individual activity chart using photographs to indicate how they were going to spend their day. Staff explained how it was important that their routines were maintained and that they and staff provided a consistent approach to minimise anxieties. People said they liked shopping and were observed being supported by staff to plan a trip out. During one visit people had a reflexology session at the home. One person had planned a trip to the cinema. Staff said that people helped to bake cakes and do arts and crafts. They also said that they had an allotment where they were planning to grow vegetables. People had taken holidays last year and were planning holidays for this year. Some people liked to go to church and attended a service each month. Daily records evidenced that people had regular contact with family and friends. One person was visited at the home by their family who also took them out regularly for Evidence: trips. Others kept in touch by letter. People were supported to develop relationships and were able to have space and privacy in communal areas or their own rooms. Staff described how they supported people to get involved with day to day chores around the home and to help out no matter how small the contribution. Step by step plans were in place breaking down tasks enabling people to take things at their own pace. People were observed helping to clear the table. Daily dairies indicated that they also helped with their laundry, cooking, laying the table and helping to make drinks. Menus had been developed to reflect peoples likes and dislikes. Although menus were in place for a three weekly period of time there was a great deal of flexibility. Staff said that people were being supported to choose a meal each week for which they would shop and then help prepare or cook. Meals were freshly produced using fresh ingredients. Some people bought themselves additional snacks and had cupboard space in which to store these. Fresh fruit was available for people in the kitchen and they were observed having drinks throughout the visits. Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Peoples health and personal care needs are being met helping them to stay well. Their health and wellbeing are promoted by satisfactory arrangements for the handling of medication. Evidence: The ways in which people liked to be supported with their personal care needs were clearly and succinctly recorded in their care plans. Peoples preferred routines for going to bed, getting up and support with bathing or showering were identified. Some people were observed wearing bibs during mealtimes and when having drinks, whereas others wore aprons. The latter were less institutional. Where needed listening devices, bedsides and an alarm pad were being used to make sure people were safe and their personal care needs addressed promptly. Records confirming the rationale for these were in place. Each person had a Health Action Plan in place which monitored appointments with a range of health care professionals. There was evidence of close working with the Community Team for People with a Learning Disability (CTPLD). Referrals had been made to Physiotherapy and Speech and Language Therapy when needed. People were having regular reviews of their medication with their Psychiatrist. Appointments were being recorded with a summary of the outcome of the appointment. Systems for the administration of medication were examined and found to be satisfactory. The temperature of the cabinet needs to be monitored daily and recorded ensuring that medication was being stored at below 25 degrees centigrade. Staff were completing training in the safe handling of medication. A staff signature list was in place and care plans giving consent for staff to administer medication were in place. Regular stock checks were in place and medication stored appropriately. The homely Evidence: remedies list was signed in 2004 this should be reviewed with authorisation from either the pharmacy or the Doctor. There were protocols in place for the administration of as necessary medication. Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Processes are in place that enable complaints and concerns to be raised by people using the service or on their behalf. Systems safeguarding people from possible abuse will be strengthened by providing training to all staff. Evidence: The home had a complaints policy and procedure in place which had been produced in a format using pictures, text and symbols. There were also copies of Turning Points complaints procedure in the home. They monitor complaints and compliments on a monthly basis. The home had not received any complaints. The AQAA stated, service users are empowered to make their wishes known as evidenced in diarys, support plan. House meetings were being held on a regular basis to pass on information to people and provide a forum to express concerns. Staff had a good understanding of the safeguarding of adults and their role in identifying abuse. The AQAA indicated, Staff are experienced in observing changes in mood and behaviour that could indicate unhappiness. Staff challenge each other if they are concerned regarding other staffs behaviour. Discussions with staff confirmed this and they stated that they had confidence in the registered manager and that she would challenge poor practice and deal with it appropriately. The training matrix indicated that all staff needed training in the safeguarding of adults. One person had completed the training in 2007. This must be completed. Financial records were examined and found to be satisfactory. Staff confirmed that people living in the home were not paying for staff meals or drinks when they accompany them out. However it appeared that some staff expenses were still being funded by people living in the home. Staff said that this was a temporary measure and thought it would not be in place in the new financial year. The registered manager later confirmed that wherever possible people would not pay for staff expenses. The Statement of Purpose identified that people would have to pay for activities. It appeared they also pay for staff accompanying them such as to the cinema. This should be kept under review. Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . People live in a home that is safe, clean and well maintained which recognises their diverse needs creating an environment that matches their personal requirements. Specialist equipment is provided to those people who need it. Evidence: The home provides spacious accommodation for people with specialist adaptations where needed. Communal areas had been redecorated and were looking clean, light and well kept. Corridor walls on the first floor needed some attention but staff were aware of this. They said they help to redecorate when they can with professional decorators being commissioned to paint stairwells and more difficult areas. One person said they liked their newly decorated room and the colour scheme. Peoples rooms were individualised reflecting their lifestyles and personalities. An assisted bath was provided on both floors and a mobile hoist had been supplied for use by one person. Since the last inspection the kitchen had been totally refurbished with new fixtures and fittings and washable floor. Good food hygiene practice was observed to be in place. Liquid soap and paper towels were supplied near the hand wash basin. Personal protective equipment was provided for staff. Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Peoples needs are met by a competent staff team, who have access to a comprehensive training programme that provides staff with the opportunity to gain knowledge about the diverse needs of people living at the home. Recruitment and selection systems should protect people from possible abuse. Evidence: The AQAA stated, Staff have been working in service for many years so well, have received good training and are well experienced. Staff spoken with confirmed this and from observations during the visits appeared to work well together. They were knowledgeable about the needs of the people they support. Staff said that levels were appropriate to peoples needs with some flexibility in the rota to allow for additional support if needed. Any shortfalls in the off duty were covered by the team or members of the bank team. Turning Point was providing an induction for new staff and also access to Learning Disability Qualifications. A National Vocational Qualification (NVQ) programme was in place. The DataSet confirmed that over 70 per cent of staff have a NVQ in Health and Social Care. There had been no new appointments of staff to the home since the last inspection. Several staff files were sampled and each contained a checklist providing information required by us about recruitment and selection records obtained prior to employment. The home was advised not to keep copies of birth certificates or Criminal Record Bureau checks in line with requirements of the Data Protection Act. The home had a training matrix in place which clearly identified what training each member of staff had completed, their future training needs and when refresher training was due. Staff said that a new system of learning was being introduced which involved distance learning modules. They were being allowed time during their working Evidence: day to complete these. Staff also confirmed that where identified specialist training with external trainers was sourced such as death and dying, dementia care and autism awareness. The local CTLPD also provided training in the home. Equality and Diversity training had been identified for all staff. Some staff had attended training in the Mental Capacity Act. Staff said that supervision or 1 to 1 meetings and Annual Appraisals were taking place. Most staff had between 4 and 6 supervision sessions and all had an annual appraisal in 2008. Staff meetings were being held regularly. Staff confirmed that communication was good with a hand over at each shift and the use of a communication book. Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . People benefit from a well run home. Quality assurance systems are being put in place which will involve people who live there. Satisfactory health and safety systems are in place providing a safe environment. Evidence: The registered manager has a nursing qualification and a NVQ Level 4 with Registered Managers Award. Staff said she was approachable and they had confidence in her management skills. She had completed an AQAA and forwarded this to us before the required deadline. She had endeavoured to meet all requirements issued at the previous inspection. Turning Point were introducing a new quality assurance system, an Internal Quality Assessment Tool which the registered manager had made a start on compiling evidence for each audit. It was not clear whether a report would be produced each year as a result of this audit. Turning Point had also an audit which according to the AQAA, provided advice for staff to support people with learning disabilities to make decisions about their lives and choices about the options open to them. There had again been problems with the monthly unannounced visits to the home by a representative from Turning Point required by us under Regulation 26. Two visits had been conducted in 2008 and one in January 2009. The reports for 2008 were examined and found to include feedback from staff and observations of people living in the home. Staff confirmed that a new area manager would be conducting monthly visits to the home to comply with Regulation 26. Systems for the monitoring of health and safety within the home were found to be satisfactory. Staff explained how they had received training appropriate to their roles Evidence: and responsibilities for monitoring health and safety and fire systems. Records were found to be in place and systems monitored appropriately. A fire risk assessment was in place which had been reviewed in November 2008. Monthly health and safety checks were in place with outcomes of any identified shortfalls recorded as they were resolved. Accident records were kept securely and it was evident that Turning Point were monitoring incidents in the home. Staff were advised to remove accident reports and store separately from the accident book to comply with Data Protection. Are there any outstanding requirements from the last inspection? Yes  No  Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No Standard Regulation Requirement Timescale for action 1 38 26 (2) The registered provider must 04/02/2008 ensure unannounced visits are made monthly in accordance with the regulation. Requirements and recommendations from this inspection Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No Standard Regulation Description Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set No Standard Regulation Description Timescale for action 1 23 13 The registered person must make sure that people are safeguarding from abuse by providing staff with the appropriate training, knowledge and skills. 28/08/2009 This is to make sure staff can recognise possible abuse and prevent people from being harmed, abused or put at risk. 2 39 24 The registered person must 24/05/2009 produce a report based upon their annual quality assurance system. This is to make sure that the views of people using the service are noted and responded to. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 2 3 4 5 6 7 8 6 7 18 20 20 23 34 41 Care plans and other related documents should be frequently reviewed. Copies of peoples bank accounts should be kept in the home. The use of bibs should be reconsidered in favour of more personalised aprons or other protective clothing. The homely remedy list should be reviewed with authorisation from the pharmacy or Doctor. The temperature of the medication cabinet should be monitored and recorded. Payment for staff expenses when accompanying people on activities should be kept under review. Copies of birth certificates and Criminal Record Bureau checks should not be kept. Accident records should be kept securely and not left in the accident book to comply with Data Protection. Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). 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