Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 10/10/05 for Lisieux House

Also see our care home review for Lisieux House for more information

This inspection was carried out on 10th October 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The Lisieux Trust provides comfortable, spacious accommodation in a town centre location. The Trust is an established provider of care. The service promotes independence and self-reliance. Staff encourage service users to play an active role in the day-to-day life of the home. The house has a relaxed and welcoming atmosphere. Staff encourage parental and family involvement.

What has improved since the last inspection?

Staffing levels have been increased in the mid evening to provide for improved leisure activities. The service has a permanent registered manager. The Manager has fitted safety door closures to all fire doors, which allow for ease of access and close automatically when the fire alarm sounds. The buildings have been improved; an en suite bathroom has been added to one bedroom, basins in two others, an extra bedroom is being created in the bungalow, there are new carpets and rooms have been redecorated.

What the care home could do better:

There must be a system to ensure and check that medication is being given and recorded safely. The Manager needs to ensure that staff absence can be covered at short notice to maintain reasonable staffing levels. A fire safety risk assessment must be put in place that covers both the house and the bungalow and fire safety checks must be undertaken and recorded.

CARE HOME ADULTS 18-65 Lisieux House 50 Birmingham Road Sutton Coldfield West Midlands B72 1QP Lead Inspector Christy Wannop Unannounced Inspection 10th October 2005 1:30 Lisieux House DS0000016994.V253050.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Lisieux House DS0000016994.V253050.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lisieux House DS0000016994.V253050.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Lisieux House Address 50 Birmingham Road Sutton Coldfield West Midlands B72 1QP 0121 355 1474 0121 355 1474 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) Lisieux Trust Catherine Moran Care Home 11 Category(ies) of Learning disability (11) registration, with number of places Lisieux House DS0000016994.V253050.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years with a learning disability Date of last inspection 18th March 2005 Brief Description of the Service: Lisieux House is an attractive domestic property comprising of three floors and a separate modern bungalow situated on the edge of Sutton Coldfield town centre. Together these properties provide accommodation for eleven adults with a learning disability. The homes are well situated for the local amenities, being close to bus and train routes and Sutton’s leisure and shopping facilities. The main property, Lisieux House has a large lounge and separate dining room, a kitchen/diner, seating in a number of quiet areas and toilets and bathrooms. All bedrooms are of single status. Furniture, fixtures and fittings are of a very high standard. Bartres Bungalow is situated at right angles to the main property and beyond its rear garden. The bungalow currently accommodates three service users in three single rooms. The communal areas comprise of a lounge, kitchen/diner, a large laundry that is also used by service users to sit in and a well-appointed rear garden. The furniture in this property is also of a very high standard. Situated between the two premises and to the right of the garden of the main house a garage has been converted into an activity room. There is a dedicated parking area situated behind both properties with sufficient space to accommodate five vehicles. Lisieux House DS0000016994.V253050.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over an autumn afternoon and evening. One inspector visited the home and spoke with staff, service users and two relatives. Eleven residents and three care staff were present at different times over the course of the day. The inspector spoke with the Manager on the telephone, she had been on a training course during the day. Service users completed questionnaires with the inspector and staff supported some. Their comments have been incorporated into this report. “I like all the staff” “ It’s a nice home”. People liked being able to go out and visit friends and family. Some records were viewed; some were inaccessible in the manager’s absence. The Inspector ate dinner with residents. Whilst the Manager had taken action to improve most of the areas identified by the inspector at the last inspection, serious concerns were again raised with the manager about poor medication administration and lack of records for fire testing. These were required to be immediately rectified. The Manager responded immediately to these matters. The inspection was positive and the inspector confirmed the generally good standards of care that have been established at this small, town centre home. Lisieux House provides good quality care to people with learning disabilities who are independent. What the service does well: What has improved since the last inspection? Staffing levels have been increased in the mid evening to provide for improved leisure activities. The service has a permanent registered manager. Lisieux House DS0000016994.V253050.R01.S.doc Version 5.0 Page 6 The Manager has fitted safety door closures to all fire doors, which allow for ease of access and close automatically when the fire alarm sounds. The buildings have been improved; an en suite bathroom has been added to one bedroom, basins in two others, an extra bedroom is being created in the bungalow, there are new carpets and rooms have been redecorated. 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. Lisieux House DS0000016994.V253050.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lisieux House DS0000016994.V253050.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): We looked at the outcomes for standards 2 and 3. Both of these standards are met. There is an assessment prior to people coming to live at the home to ensure that needs can be met. Goals and aspirations are well documented and these goals are reviewed with the involvement of parents and service users. The service is well able to meet the needs of the people who live at the service. Each service user has a written contract and statement of terms and conditions. EVIDENCE: The Manager has a detailed assessment and combined care-planning process to assess prospective residents needs. Care plans of two residents were seen and residents spoken to. It was not clear from documents how mental health needs had been assessed for service users with a history of this. A requirement had been made at the last inspection about an accessible service users’ complaints procedure being available in the Statement of Purpose. Staff could not find this document in the home Service users can all speak for themselves and were able to tell the inspector their views of the service. The most recent resident described her “settling in” Lisieux House DS0000016994.V253050.R01.S.doc Version 5.0 Page 9 process and clearly felt confident that the manager and staff respected her views and her plans for future independence. She said she was happy after the initial strangeness of leaving her family home. One said that they would like to move from one house to the other. One person said that he enjoyed the “good company” and being “ surrounded by lovely people”. Staff have been trained and are aware of the care needs of service users. Records and discussions with staff showed that care needs were not challenging and were being met. Lisieux House DS0000016994.V253050.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): We looked at outcomes for standards 6 and 9. Both of these standards are met. Care plans are generally satisfactory, being full and informative. Changing needs are reviewed and care plans updated to guide staff in how to support service users. Written information within each care plan about “ where do I get my money from” was excellent. The service promotes service users to do things for themselves and has a satisfactory method of assessing risks. Staffing levels both rely on and promote an independent lifestyle. EVIDENCE: Care plans seen identified short and long-term goals and were written in way that promoted people to be involved in their own plan. Service users confirmed that they knew they had a plan. One service user corrected some factual inaccuracies when reading it with the inspector. Lisieux House DS0000016994.V253050.R01.S.doc Version 5.0 Page 11 One person was keen to move into greater independence and had begun to have conversations with the manager about this. Another had not yet discussed this with their key worker though was clear about their intentions. A service user talked about the 6 weekly meetings where they could discuss matters. He said the manager did not attend these meetings. Records showed that the Manager encouraged staff to be non judgemental in their recording of service user information. Residents are also encouraged by staff to complete their own daily diaries. Risk assessments were in place and had been updated when needs changed. Lisieux House DS0000016994.V253050.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 14 was met. The service promotes independent activity and provides staffing for some limited supported leisure activities in groups. Holidays are imaginative and much enjoyed by service users. The service has a lively atmosphere. Recreational, social, religious and cultural needs are met. Families and friends are encouraged and welcomed to maintain contact and play an active role in the daily life of the home to ensure that people have choice and control over their life. EVIDENCE: Staffing levels on the day of inspection were 1: 7 service users, rising to 3:11 during the middle section of the evening when one staff took some people to an aqua aerobics class. Opportunities for service users to go out one to one with their key worker or in small groups for spontaneous evening activities, such as going to the cinema, appeared difficult to schedule. Staff reported Lisieux House DS0000016994.V253050.R01.S.doc Version 5.0 Page 13 difficulties with taking service users out, because of low staffing but also because service users were fairly reluctant to go out! Records showed that it had not been possible for service users to go out to the cinema when they wanted because there were not enough staff on duty. Service users did not raise this as a negative issue. During the inspection people were going out for hairdressing appointments and to and from day activities. There is a “driver”, who transports people to daytime activities such as college and appointments. The manager ensures that each shift has a competent driver to take people out in the house vehicle. Service users told the inspector of their holidays and showed photos: a Mediterranean cruise, active Devon holiday and a more sedate quiet UK holiday. These were clearly well planned and much enjoyed. Lisieux House DS0000016994.V253050.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): We looked at the outcomes for standards 19 and 20. One of these standards was met. The service provides a relaxed but well organised setting where people with a variety of low level health and emotional needs can be cared for. The home has a satisfactory medication policy and procedure and the manager ensures staff are trained. Staff recording and administration of correct drugs was unreliable and inaccurate. This places people at risk who are reliant on medication to maintain their health. EVIDENCE: People living at the service appeared to be well and happy. All were able to describe their feelings about the care they received and the people who worked with them. Two parents said that they were confident in their children’s well being at the home and staff’s ability to take good care. One service user had had a period of ill health and declining mobility, but his care plan and staff comments, showed that his abilities were improving again. His care plan had been appropriately reviewed and updated as his needs changed. Lisieux House DS0000016994.V253050.R01.S.doc Version 5.0 Page 15 During the inspection it was apparent from records and discussions that medication had been incorrectly administered on a number of occasions. Meeting minutes showed the manager to be aware and taking action to prevent further occurrence, but there had been two further drug errors over the weekend preceding the inspection, of medication being given but not recorded or not given at all. Whilst policy, procedure and training for administration of medication is satisfactory, the practice of this has been of concern through the last two inspections. The manager should consider what safety checks could be built in each shift by senior staff/shift leader to reduce the medication errors and shorten the time from error to discovery. Lisieux House DS0000016994.V253050.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): We looked at the outcome for standard 22. This is met. Service users are confident that their views are important and can take these to the manager. The service aims to value, protect and respect the people who live there. EVIDENCE: Service users and parents raised no concerns about lack of protection. Service users said they felt safe and knew to whom they would talk to if they had a problem or a complaint. Two people raised worries about staff attitude, shouting and being scared of being “told off”. There was evidence that the manager was addressing concerns from parents, though this was not recorded in the complaints file. There have been no complaints or reports of abuse in relation to the service made to the Commission for Social Care Inspection. Lisieux House DS0000016994.V253050.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): We looked at outcomes for standards 24 and 27 and 29 and 30. All are met. Service users have a well maintained, well decorated and comfortable home close to local amenities. The home is clean and hygienic. The service cannot offer full access to people with physical disabilities but provides for the disabilities of those currently living there. EVIDENCE: The house is warm, clean and comfortable. Service users were pleased to show the inspector their home. Records showed that repairs were carried out promptly. Renovations are underway in the bungalow to create an additional bedroom and new laundry from the old laundry/utility room. All service users have single bedrooms and said they had easy access to toilets and bathrooms. Service users in the house said they could choose whether to look after the keys to their bedrooms. Bedroom doors in the bungalow are not lockable, nor did people have secure lockable storage. A service user said that she had asked the Manager for a key. Care plans seen had a section where people had ticked what furniture they wanted and needed in their rooms. Some bedrooms are small and did not Lisieux House DS0000016994.V253050.R01.S.doc Version 5.0 Page 18 have adequate space for personal possessions and additional furniture such as a chair. Some service users said they wanted more space. One said that it was good to have her own space. The kerb outside the home does not allow for wheelchair access, though no one in the home uses one. There are steps to the fronts of both houses. One service user has had a period of reduced mobility last year and grab rails had been fitted and a portable rising bath chair obtained. Neither of these aids are now required or being used and no service user has need of specialist mobility equipment. A new “loop” system has been fitted in the bungalow lounge, kitchen and bedroom to assist someone with hearing impairments. The home has policy and procedure for control of infection. This should be dated. Both laundries are situated directly off the kitchens in the two houses. Lisieux House DS0000016994.V253050.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): We looked at the outcomes for standard 33. This standard was not met. A requirement was made at the last inspection to ensure recruitment records were available for inspection at the house. Staff were unable to access these confidential records without the manager. Staff are sympathetic to and knowledgeable about the needs of service users. Handovers are well organised to ensure full transfer of information between shifts. Staff sometimes work long shifts at times of staff shortages. service users at risk if staff are stressed or over tired. EVIDENCE: Two staff sleep in each night, one in each building. There is male and female staff. The inspector observed a handover between shifts and was impressed by the thorough exchange of information between staff. It was apparent during the inspection that there were insufficient staff to fill the gaps in the rota caused by sickness and staff training. One staff member had been on shift for 48 hours without a break. During the inspection this staff member was alone with 8 service users during the day until 3pm when a second staff member arrived. A service user was aware of the short staffing Lisieux House DS0000016994.V253050.R01.S.doc Version 5.0 Page 20 This can put and seemed preoccupied asking who had been contacted to come in and work to fill the gap. Two service users commented that some staff shout. This could be a consequence of stress. One said that staff did not like being challenged. A third member of staff worked during the evening specifically taking people out to an evening activity. One day centre was closed so service users were unusually at home, though not unexpectedly. The rota showed that there are usually 2/3 staff to 11 service users across the two buildings. The Manager later reported that agency staff could be used (though were not used on this occasion.) The manager reported plans to build up a “ bank” of staff available to fill emergency gaps in the rota. Lisieux House DS0000016994.V253050.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 41,42 There are shortfalls for both these standards. The service has generally well organised record keeping arrangements with the exception of records for medication, fire safety checks and complaints. Whilst generally the health and welfare of service users is protected, there is a continuing shortfall in the standard regarding fire safety and administration of medication. Arrangements for confidential storage/archiving of information are not satisfactory and should be improved. EVIDENCE: There was evidence in the staff meeting minutes and in comments made in the “Communication Book” of the manager’s style and prompt focus of attention on areas for improvement. Lisieux House DS0000016994.V253050.R01.S.doc Version 5.0 Page 22 It was not possible to examine all records required for regulation as the manager was not present and staff did not have access to all information, such as staffing records. A range of records was inspected and found to evidence satisfactory practice with the following exceptions. Current service user records were kept in a locked cabinet. There was a box of what appeared to be historical care plans and files in the dining room. This is not confidential. Fire records in the bungalow did not show that safety checks were being carried out. There was no fire safety risk assessment in the bungalow or the house that referred to the bungalow. At the last inspection a requirement was made about inadequate fire checks and a requirement was made at this inspection to rectify this immediately. The manager has subsequently reported that she has taken effective action to improve the situation. Medication records showed incorrectly administered medication. Whilst general recording showed that the manager was sorting out complaints, this was not evident form the official “Complaints Record”. Lisieux House DS0000016994.V253050.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X 3 X X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X 3 X 3 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X 2 X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Lisieux House Score X 3 1 X Standard No 37 38 39 40 41 42 43 Score X X X X 2 1 X DS0000016994.V253050.R01.S.doc Version 5.0 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 4(1) c Requirement Timescale for action 18/04/05 2 3 YA20 YA33 The Statement of Purpose must include details of the arrangements for service users to make complaints 13(2) The manager must ensure that medication is administered as prescribed by the GP. 12, 18, 19 The manager must ensure that staff are rested and fit to work shifts and that long shifts are formally monitored at supervision. 18 The manager must ensure that there are sufficient staff to cover for emergencies, holidays and staff sickness. The organisation must operate and adhere to a robust recruitment system and ensure that staff records include those items stated in Schedule 2 of the Care Homes regulations (2001) are available for inspection. The manager must ensure that all precautions are taken against the risk of fire in the bungalow as well as the house, including a fire risk assessment and recording of routine checks. DS0000016994.V253050.R01.S.doc 10/10/05 31/01/06 4 YA33 31/01/06 5 YA34 7,9,19, Sch 2 18/03/05 6 YA42 13, 17 Sch 4:14, 23 10/10/06 Lisieux House Version 5.0 Page 25 7 YA41 12,17 Confidential information about service users must be safely stored. 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA24 Good Practice Recommendations The Trust should consider what additional improvements can be made to the premises so that it meets the requirements of the Disability Discrimination Act 1995 Part Three Policies and procedures should be signed, dated and indicted when reviewed. Arrangements for a private lockable area/door/storage should be considered with service users in the bungalow. The manager should ensure that complaints are satisfactorily logged in accordance with the homes’ complaint’s procedure. The Manager should speak privately with each service user as part of the quality assurance scheme to ensure that private worries are acted on. 2 3 4 5 *RCN YA26 YA41 YA39 Lisieux House DS0000016994.V253050.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Lisieux House DS0000016994.V253050.R01.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!