Inspection on 18/07/07 for Holmdale Care Home

This inspection was carried out on 18th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Holmdale Care Home 26/09/06

Holmdale Care Home 15/11/05

Holmdale Care Home 24/02/05

Holmdale Care Home 10/08/04

Holmdale Care Home 03/03/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Holmdale Care Home 2a Companys Close Weston Village Runcorn Cheshire WA7 4NA Lead Inspector Maureen Brown Unannounced Inspection 18 July 2007 09:30 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 Holmdale Care Home DS0000005143.V332761.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. Holmdale Care Home DS0000005143.V332761.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holmdale Care Home Address 2a Companys Close Weston Village Runcorn Cheshire WA7 4NA 01928 581448 01928 589946 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) www.c-i-c.co.uk Community Integrated Care Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Holmdale Care Home DS0000005143.V332761.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of six service users to include: * Up to 6 service users in the category of LD (Learning Disability) excluding dementia. 26th September 2006 Date of last inspection Brief Description of the Service: Holmdale is a residential care home providing personal care for six adults with learning disabilities. At the time of this visit four adults were living at Holmdale. Holmdale is owned and managed by Community Integrated Care, a not for profit organisation. The home is located in the Weston Point area of Runcorn, near to a local shop and pub. Car parking is available to the front and side of the building. A small garden and patio area to the rear are fully accessible to the service users. The staff team comprises of a new manager who is supported by the deputy manager, eight support workers and a cleaner. The home is a purpose built dormer bungalow with only staff facilities upstairs. Residents’ accommodation is on the ground floor. All the bedrooms are single with fitted bedroom furniture. There are no en-suite facilities. There are two assisted bathrooms plus a separate assisted toilet within easy reach of bedrooms and communal areas. There is a large lounge/dining room, a kitchen and a utility room. The fees at Holmdale range from £352.30 to £358.70 per week. Fees are calculated on individual assessment. Optional extras include CD’s, Videos, DVD’s, holidays, magazines, clothing, toiletries and hairdressing. Holmdale Care Home DS0000005143.V332761.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector visited without an appointment on 18 July 2007. The visit took six hours. The information reviewed included the previous inspection report, service history and other information received about the service. The site visit included a tour of the communal areas and some bedrooms, inspection of records and discussions with residents, the manager and the support workers on duty. Twenty-four out of forty-three standards were assessed and all were met. All the key standards were assessed. Requirements made at the previous inspection had been met. None of the service users have verbal communication skills. Staff interpret body language to ensure service users needs are met. Surveys were made available for service users, relatives and other professionals to complete. Service users commented that “I have a varied social life. Staff understand my needs through my body language”, “All staff know me to a high standard so know what I am trying to say”, “We have a very hard working cleaner who keeps smells and odours to a minimum” and “A number of staff helped me fill in this form so that they didn’t miss anything out that I was trying to say.” Relatives commented that “The staff are very good and they understand my relatives needs very well”, “The staff do a wonderful job”, “The bungalow is kept very good” and “The staff do all they can”. Feedback was given to the manager at the end of the site visit. What the service does well: The home has an established staff team who are keen for high standards to be maintained. This meant that the staff team was adequately meeting the complex needs of the residents. Residents’ care plans and case notes were well documented and reflected the individual residents’ needs. This meant that residents were well supported by the staff team. The home maintains good standards within the home so that residents were living in an adequate environment and checks were in place to show that residents and staff safety was protected. Holmdale Care Home DS0000005143.V332761.R01.S.doc Version 5.2 Page 6 The staff managed daily activities and entertainments well and residents confirmed that they were pleased with the choices on offer. 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. Holmdale Care Home DS0000005143.V332761.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 Holmdale Care Home DS0000005143.V332761.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good information is provided for residents to make a decision about moving into the home. EVIDENCE: Information about the home was in the statement of purpose and function and residents’ guide. This had been developed in a mixture of standard and large print with pictures of the home both internally and externally shown. The information included details of the mission statement and philosophy of care, role of the key worker, staff structure and terms and conditions of residence. The last inspection report was available. The information provided a full picture of the home. It was written in plain English. The previous requirement regarding reviewing the statement of purpose and service user guide had been met. They had been reviewed in March 2007. Within the statement of purpose the underlying theme of promoting “physical, intellectual and the psychological well-being of the residents” is seen. Also respect, choice, privacy, rights and ambitions of residents are promoted. The CIC mission statement states “enable individuals to have a life rather than an existence”. These themes are reflected in all the policies that were seen and throughout the ethos and working in the home. Holmdale Care Home DS0000005143.V332761.R01.S.doc Version 5.2 Page 9 The care needs assessment was seen in service users files. This contained all the information required to ensure that the home can meet service users needs. Included were Next Of Kin information, personal support and care needs and medical information. This is completed initially and used in conjunction with the social services information. All the current service users have lived in the home since 1991. However a prospective service user is currently visiting the home. Their pre assessment documentation included pre assessment form, copy of essential lifestyle plan, eating and drinking guidelines, care plan review by social worker, preadmission meeting notes and details of visits made in daily log sheets. Good details had been recorded and this person is currently visiting twice a week with a view to moving in. Holmdale Care Home DS0000005143.V332761.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 & 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents’ health, personal and social care needs are met by the staff team who enable them to maintain their privacy and dignity. EVIDENCE: All four residents’ files were seen. These were presented in individual ring binders and contained all the information necessary for staff to care for the residents. Included in the files were copies of the service users guide, summary of abilities and activities of daily living. All these were clearly detailed and were up to date. Social services reviews were up to date. The care plan files contained many photographs of service users enjoying activities etc. Since the previous visit a communication dictionary for each service user had been developed which stated when I do ………it means…and you should…. This was a very useful tool for the staff team. Care plans were accurate, well recorded and documents were kept safe and secure in a locked cupboard. Holmdale Care Home DS0000005143.V332761.R01.S.doc Version 5.2 Page 11 In a separate file the daily records and personal activity programmes were seen. There was a good record of daily activities, which were well recorded and appropriate to each service user. Service users said they were able to make their own decisions about what to do during the day and staff, as needed supported this. Risk assessments were available and a range of activities were recorded such as moving and handling, incontinence and personal. All had been reviewed in May 2007. The people who use the service commented that “the staff treat me well” and “knowing me well helps them to understand my needs”. Holmdale Care Home DS0000005143.V332761.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 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ were able to take part in a range of activities. Personal and family relationships were encouraged by the home and the staff team supported people with this. EVIDENCE: The residents’ plan reflects the range of activities undertaken which included a “lifestyle” programme of mainly daily living activities, such as baking, beauty treatments, videos, DVD’s, listening to music, passive exercise, sensory stimulation and individual time with staff members. Activities outside the home included shopping, visits to the cinema, bowling, meals out, visits to the hydrotherapy pool, holidays, going for walks and visits to the local pub. The residents were involved in “SPACE”, where there are ball pools, bubble tubes, large snoozelum and other activities available. Residents spoken to said, “it was great there”. Daily routines of residents were clearly documented in the care plans and these were well written. Residents access the local community in their own adapted transport. Holmdale Care Home DS0000005143.V332761.R01.S.doc Version 5.2 Page 13 One service user commented “I can do anything I wish to do, money permitting.” Staff said that some residents received visits from family members and that they enjoyed these. Residents could see visitors within their own room or in the shared living areas. During a tour of the home some residents were seen spending time alone in their rooms whilst others were enjoying social contact with others in the lounge/dining area. Educational needs of service users had been addressed. Contact with local colleges confirmed that they had not been able to offer suitable courses, so at this time they are not engaged in educational and occupational pursuits. The manager stated that if a service user or their family thought something would be useful then this would be pursued on their behalf. The home provides a four-week menu. A good variety of meats, cheese, fish were included and also fresh vegetables and fruit. Each service user has an individual menu sheet where meals and drinks are recorded. It was seen that on occasions this was blank and sometimes the planned meal had not been taken. A record should be made of when the menu plan is changed and a recommendation was made regarding this. Holmdale Care Home DS0000005143.V332761.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents’ health, personal and social care needs are met by the staff team who enable them to maintain their privacy and dignity. EVIDENCE: Personal care and support are provided in service user own room or bathroom. Support is given in line with service user plan details. Residents were dressed differently according to their own choice. All aids and adaptations required for the residents were provided and these included equipment such as tracking equipment in the bathroom and a shower and changing trolley. Service users stated, “I find the staff very friendly and accommodating to my every need” and “All staff know me to a high standard so know what I am trying to say”. Healthcare information had significantly improved since the previous visit. All service users had received a medication review and annual reviews of healthcare within the last year. The sheets recorded optical, dental, GP, chiropody, continence and medication dates when last seen. These were all within last year. The previous recommendation had been met. Holmdale Care Home DS0000005143.V332761.R01.S.doc Version 5.2 Page 15 The medication is kept in a locked steel cupboard within a kitchen cupboard. A monitored dosage system was used and all medication was stored appropriately. The medication administration sheets seen were signed and up to date. Unused medication is returned to the pharmacy on a monthly basis. Staff files examined showed medication training undertaken. A medication policy, patient leaflets and guidance for medication to be taken when required were available for the staff team as reference material. Holmdale Care Home DS0000005143.V332761.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives were satisfied with the support they received from the manager and staff. Clear policies and procedures were in place to ensure that residents were protected from abuse, neglect and self-harm. EVIDENCE: The home’s Protection of Vulnerable Adults Policy was seen and this was consistent with the “No Secrets” guidance from the Department of Health. A copy of the Local Authority Adult Protection policy was available within the home and accessible to staff. The home also had policies on abuse and suspected abuse, abuse guidelines, adult protection POVA guidance, whistle blowing and harassment and bullying procedures. All staff are trained in POVA during induction process, which includes watching a video, talks and the staff reading the Protection of Vulnerable Adults policy and guidance. Staff confirmed that they had received this training. The complaints procedure was seen and this contained details of the Commission and the ombudsman. The name of new Responsible Individual needs to be changed on the complaints procedure and a recommendation was made. The Commission or the home had received no complaints since the last inspection. Service users confirmed they would contact the manager if they had any problems. This was also confirmed through surveys provided by relatives. Holmdale Care Home DS0000005143.V332761.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a clean and comfortable environment for the people to live in. EVIDENCE: The overall state of repair of the home both internally and externally is very good. The communal areas and some bedrooms were seen on this visit. The home was furnished in a domestic style with additional equipment such as grab bars in toilets and bathrooms, rails along corridors and moving and handling equipment provided to meet each person’s needs. The bedrooms seen had been decorated to personal taste and personal possessions were in evidence. One service user had purchased new bedroom furniture since the last visit. Since the last visit the bath had been moved and new tracking supplied to enable better access to the bathroom facilities. Holmdale Care Home DS0000005143.V332761.R01.S.doc Version 5.2 Page 18 During the tour the kitchen was visited. This was clean and tidy. Records were seen of fridge, freezer and hot food temperatures. This ensures that correct temperatures are being maintained. The home was clean, tidy and free from unpleasant smells. All the service users stated that the home was always clean and odour free in the questionnaires received. The garden area was neat and tidy. Holmdale Care Home DS0000005143.V332761.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 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 homes recruitment policy and practices as they are consistently followed. EVIDENCE: At the time of this visit it appeared that sufficient staff were on duty. The staff team was well established and they had a wide range of experiences. This was complimented by mandatory courses undertaken, such as moving and handling, POVA, fire training and food hygiene. Other relevant courses were also available, such as optical awareness, epilepsy management and Cerebral Palsy. Six out of ten staff had completed NVQ level II and one person was due to start this award. The recruitment procedure ensures that the staff are suitable to work with vulnerable people. Three staff files were examined and these showed that all relevant pre-employment checks were carried out. The staff files were well presented and subdivided into areas making it easy to find all the relevant information. Holmdale Care Home DS0000005143.V332761.R01.S.doc Version 5.2 Page 20 Staff meetings were held on a regular basis. The last one was held on 6 July 2007 and 8 staff attended. Issues discussed included general service user issues, staff issues and service users holidays. The policy on staff states that meeting will be held every eight weeks. The manager also attends managers meetings and feeds this information back to the staff team. Day to day supervision of the staff team is good. Staff commented that they received good support from the manager and her deputy. Formal supervision was up to date and records were seen. At the previous visit it was recommended that annual appraisals should be undertaken with the staff team and this was reiterated at this visit. During discussions with the staff team they said, “the atmosphere at Holmdale is relaxed”, “I enjoy my work” and “it is very rewarding”. Holmdale Care Home DS0000005143.V332761.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health, safety and welfare of the service users are protected. The views of service users are obtained and influence the running of the home. EVIDENCE: Since the last visit a new manager had been employed. She January 2007. She has worked for CIC for twelve years and has supervisory capacity for the last nine years. She has HNC health care and NVQ 4. She is currently applying for registration Commission. started in been in a and social with the Safe working practices were in place to ensure the health, safety and welfare of the residents. These included visits from the fire safety officer and the environmental health officer, which had been completed satisfactorily. The gas safety, electrical safety and insurance certificates were in place and up to date. Holmdale Care Home DS0000005143.V332761.R01.S.doc Version 5.2 Page 22 Fire alarm tests were being undertaken on a weekly basis and records kept. Emergency lighting tests were also being carried out on a monthly basis with records kept. All staff had received fire awareness training. Accident and incident record books were seen and since the last visit when a requirement was made these have been brought up to date and the requirement was now met. A quality assurance process was in place. A selection of “thank you” cards were seen at the back of the copy of the service users guide in the home. These showed peoples appreciation of the staff and care given. Combined resident and staff meetings were held on a regular basis. It was recommended that these meetings be split and separate ones conducted. Also views of service users, their representatives and other professionals are gathered during service users reviews. The commission on a monthly basis receives regulation 26 visit information. The service manager conducts these. CIC have a satisfaction survey that is sent out annually to all the people who use their services. This information is amalgamated and put into one document. The last one was dated 2006/7. The findings were split into service areas but not individual homes. The overall findings stated that: • • • 97 clients stated that staff treat them well; 94 staff encourage clients to be independent; and 93 clients state that from receiving support from CIC their lives had improved. The company completed this, rather that specifically at the home. The results of the survey indicated that service users were happy with the care they received and the food and premises were good. Relatives confirmed they were happy with the care provided and staff said they were also satisfied with their role. A recommendation was made during the previous visit to ensure that the management takes the views of service users and their representatives into account regarding the running of the home. These finding should be analysed and shared with service users, their representatives and other stakeholders and the recommendation was reiterated. Holmdale Care Home DS0000005143.V332761.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 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 3 X X 3 X Holmdale Care Home DS0000005143.V332761.R01.S.doc Version 5.2 Page 24 No 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. Standard Regulation Requirement Timescale for action 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 YA17 Good Practice Recommendations The registered person should ensure that changes from the planned menu are documented and that the menu sheets are always completed to ensure that service users have received appropriate meals. The registered person should ensure that the new Responsible Individuals details are included in the complaints procedure so that people are aware of whom to contact if they have a complaint. The registered person should ensure that annual staff appraisals are carried out so that well-supervised staff supports service users. The registered person should ensure that combined staff and service user meetings are split to ensure that service users have the opportunity to voice their opinions within their own meeting. DS0000005143.V332761.R01.S.doc Version 5.2 Page 25 2 YA22 3 4 YA36 YA42 Holmdale Care Home 5 YA42 The registered person should ensure that an analysis of the homes survey information is produced and circulated to service users, representatives and other stakeholders with regard to the service user surveys. To ensure that service users comments about the home are not “lost” within CIC global analysis. 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