Inspection on 29/06/06 for Priory Close (3)

This inspection was carried out on 29th June 2006.

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

Other inspections for this house

Priory Close (3) 11/08/08

Priory Close (3) 06/06/07

Priory Close (3) 19/12/05

Priory Close (3) 01/07/05

Priory Close (3) 20/01/05

Priory Close (3) 07/07/04

Priory Close (3) 04/02/04

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 Priory Close (3) 3 Priory Close Aigburth Liverpool Merseyside L17 7EG Lead Inspector Sonya Robinson Key Unannounced Inspection 29th June 2006 09:30 Priory Close (3) DS0000025316.V287880.R01.S.doc Version 5.1 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 Priory Close (3) DS0000025316.V287880.R01.S.doc Version 5.1 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. Priory Close (3) DS0000025316.V287880.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Priory Close (3) Address 3 Priory Close Aigburth Liverpool Merseyside L17 7EG 0151 727 1886 9999 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 3 Category(ies) of Learning disability (3) registration, with number of places Priory Close (3) DS0000025316.V287880.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th December 2005 Brief Description of the Service: 3 Priory Close is registered to provide care for three adults with a learning disability. 3 Priory Close is a detached bungalow, there are three single bedrooms, a large lounge, kitchen and an office. Laundry facilities are situated in the garage. There is a garden to the rear of the home with a patio and grass areas. There is wheelchair access to the property. Bathing aids are provided. The home is situated in a quiet cul-de-sac in the Riverside district of Liverpool. Local shops and amenities can be found a mile or so from the home. Otterspool Promenade and local parkland are within walking distance. The home has access to a minibus, which has a lift. Priory Close (3) DS0000025316.V287880.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a morning. During the inspection time was spent in the office examining records and policies and procedures. Staff were spoken with. A tour of the home was undertaken. Staff were observed delivering care to service users. Prior to this inspection information was also gathered from a questionnaire filled in by the service and home owners reports. The main focus of the inspection process was to understand how the home was meeting the needs of the service users and how well staff were themselves supported by the organisation to make sure they had the skills, training and support to meet the needs of the service users. The inspector would wish to acknowledge the assistance and co-operation of the staff of the home during the course of this inspection. The inspector would also wish to particularly thank the service users for their patience and tolerance throughout the inspector’s time in their home. What the service does well: A statement of purpose and function and service user guide is available within the home. A full assessment would take place to ensure that a service user’s needs could be met before they move to the home. The daily routines and opportunities to develop and maintain relationships ensure that the emotional and social needs of service users and their preferences are provided for, activities have been expanded upon to stimulate service users. Service users are offered a healthy diet and choice is available. The personal support needs of service users are met, though improved documentation would further support this. Each service user has a satisfactory health care plan in place and the home has policies and procedures in place with regard to medication. Policies and procedures are in place, which are respectful of ageing, illness and death. There is a comprehensive complaints procedure in place though the service users could benefit from the home’s complaints procedure being more user friendly. Service users are protected by the adult protection procedures in place at the home. There are polices and procedures in place to ensure that staff are safely recruited and vetted. There are in general sufficient numbers of staff to meet Priory Close (3) DS0000025316.V287880.R01.S.doc Version 5.1 Page 6 the needs of service users. Systems are in place to ensure that service users benefit from staff having regular supervision. The quality assurance systems and management approach ensure that the best interests of service users are supported. What has improved since the last inspection? Staff training with regard to the use of rectal diazepam has been completed since the last inspection and this would be in accordance with a service user’s care plan. The medication system has also been reviewed and is easy to follow in order to safeguard against possible errors. The level of activities has been increased though it is acknowledged by the service that the needs of one service user in particular may not be fully met. The service is liaising with the placing authority in this instance. 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. Priory Close (3) DS0000025316.V287880.R01.S.doc Version 5.1 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 Priory Close (3) DS0000025316.V287880.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Sufficient information is available to enable the service users or their representatives to make a decision about the suitability of the home. There are good systems in place to ensure that a service user’s needs could be met before they move to the home. EVIDENCE: A statement of purpose and function and service user guide is available within the home. Information is available to enable the representatives of service users to make a decision about the suitability of the home. No new service users have come to live at the home since the last inspection. Records indicated that prospective service users would have a full assessment, which includes obtaining the views of the service user, relatives and health and social care professionals as appropriate. Prospective service users would be able to visit the home to meet the existing service user and staff and view the home. There is a wide variance of need between the service users. Since the last inspection activities have been increased that would help to meet the intellectual and social development needs of a service user. Discussions with Priory Close (3) DS0000025316.V287880.R01.S.doc Version 5.1 Page 9 the staff indicated that the service user has begun a college course and goes swimming on a regular basis. Through discussion with staff the inspector was informed that steps have been taken to ensure that all staff have up to date training in moving and handling, food hygiene and first aid. Since the last inspection it was reported that staff have now received training around administering rectal diazepam. This is administered in accordance with a care plan. There is information around the communication needs of service users in their care plans. It is recommended that this be expanded upon. Service users may also benefit from personal communication dictionaries so their specific methods of communication can be easily identified. Priory Close (3) DS0000025316.V287880.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Care planning reflects the assessed and changing needs of service users. Though the files would benefit from some reorganisation and updating. Risk assessments are in order to ensure these fully support service users, though staff must now familiarise themselves with these. Pictorial communication should be expanded upon and the use of this is to be encouraged to aid communication. EVIDENCE: A sample of service user plans were examined. These cover the information recommended in the National Minimum Standards and there was evidence that these plans are subject to a review. The records indicated that consultation takes place with relevant professionals regarding meeting the needs of service users. A daily record is made regarding the well being of service users. This should be expanded upon to reflect the service provided. There is also a monthly evaluation plan in place for each service user, of the sample observed, these were found in need of updating and would also benefit from further detail. Staff were found to be knowledgeable about the needs of the service users. Priory Close (3) DS0000025316.V287880.R01.S.doc Version 5.1 Page 11 The records and a discussion with staff indicated that service users are assisted to make decisions about their lives in accordance with their abilities. Records of service users likes and dislikes and preferences around daily living, such as what time they like to get up and the activities they enjoy goes to ensuring service users choices are respected. Further written information around how the service users communicate their needs would also assist in this process. A staff member was able to demonstrate that they would be respectful of confidential information and that it would be stored securely. The service has policy and procedure in place with regard to this issue. Service user’s would benefit from the services of an independent advocate Priory Close (3) DS0000025316.V287880.R01.S.doc Version 5.1 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): 11, 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The emotional and social needs of service users and their preferences are well provided for with increased opportunities to pursue activities to stimulate service users. Service users are offered a healthy diet and choice is available. EVIDENCE: The service users engage in a range of activities to develop new skills and to fulfil their social needs. One service user attends Art College but has finished now for the summer break. Where necessary staff would support service users to access activities. The service has a mini bus, which they use to enable service users to access community facilities. The home is a short walk from local shops, pubs, restaurants, churches, etc. Other parts of the town are easily accessible by public transport, which passes near the service. Priory Close (3) DS0000025316.V287880.R01.S.doc Version 5.1 Page 13 The service users have holidays, which are included in their weekly fees. Holidays have been booked for this year within the UK and are booked to take place in July and August. Due to the needs of the service user’s they tend not to go away as a group. Service users are supported to maintain and develop contact with friends and family. The service has an unrestricted visiting policy and service users are able to choose where to see their visitors. Service users rights to privacy are respected in the manner in which service users are supported with personal care etc. Service users have access to all parts of the building. Service users are not responsible for household tasks. Mealtimes at the care home are flexible to meet the service user needs. There is a menu in operation though often several different meals are served according to service user preference. Discussion with the staff indicated that a service user requiring a special diet is catered for. Priory Close (3) DS0000025316.V287880.R01.S.doc Version 5.1 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): 18, 19, 20, 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The personal support needs of service users are met, though improved documentation would further support this. Each service user has a satisfactory health care plan in place and the home has policies and procedures in place with regard to medication. Policies and procedures are in place, which are respectful of ageing, illness and death that inform staff about how to support service users sensitively according to their preference. EVIDENCE: There is information available for staff on service users personal care routines that indicate service users preferences. Though as mentioned previously some would benefit from including further detail. Staff were aware of the morning and evening routines of each service user and individual support needs. Healthcare plans were found to be in place for service user’s, which highlighted their needs, and appointments, which are supported by staff. The medication procedure gives clear guidance to staff. The medication records and corresponding medication were examined and found to be in Priory Close (3) DS0000025316.V287880.R01.S.doc Version 5.1 Page 15 order. Medication is stored securely. Members of staff reported that they have been trained in the administration of medication that reduces the likelihood of any possible errors in the administration of medication. The service has a policy and procedure in place in relation to ageing, illness and death of a service user. Priory Close (3) DS0000025316.V287880.R01.S.doc Version 5.1 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): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There is a comprehensive complaints procedure in place though the service users could benefit from the home’s complaints procedure being more user friendly. Service users are protected by the adult protection procedures in place at the home. EVIDENCE: The home has a detailed complaints procedure with timescales for action and responses to concerns raised. There is also a shorter version that is made available to service users and their family/advocates. The inspector has received information that the organisation are giving consideration to making the complaints procedure more suitable to the needs of the service users living at the home. It is acknowledged that the current service users may not benefit from this. No complaints have been made to the Commission for Social Care Inspection about the home since the last inspection and no complaints have been made to the home. The home has an adult protection procedure and a copy of the Liverpool City Council’s adult protection procedures is also available. A whistle blowing policy is available. The staff spoken with had received training in the adult protection procedure and this helps to ensure that they would be able to recognise and act upon any concerns that may have about the welfare of the service users. Priory Close (3) DS0000025316.V287880.R01.S.doc Version 5.1 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): 24, 25, 26, 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home is clean and generally well presented and provides a comfortable and pleasant environment for service users although as with any domestic dwelling there are several areas requiring attention. A safe environment is in general maintained. EVIDENCE: A tour of the home indicated that the home is well maintained and comfortably furnished. The home was registered prior to the introduction of National Minimum Standards. The size of the bedrooms does not comply with the current space standards outlined in the National Minimum Standards. There is a large living room available for communal living. The kitchen is quite small so meals tend to be eaten in the living room or service users bedrooms if they require. A suitably adapted shower room is provided. There is a pleasant, well-maintained garden available for service users. This comprises a grass and patio area. There is ramped access to the garden through the kitchen and patio doors. Access to the front door is via two small steps. The service has Priory Close (3) DS0000025316.V287880.R01.S.doc Version 5.1 Page 18 benefited from a new bathroom floor covering since the last inspection along with several items of electrical equipment in the kitchen and bedroom furniture. As with any domestic dwelling there are now a couple of areas that require attention; carpets throughout the home would benefit from being cleaned or replaced as they have become stained in areas. The kitchen floor covering requires repair or replacement as it has started to lift in parts. The mattress and bed frame are to be removed from the garden at the side of the house. There is a garage available, which is used as a laundry room and for storage. Specialist equipment to maximise service users independence is provided following a suitable assessment. The home was clean. Staff have designated responsibilities for ensuring the cleanliness and tidiness of the home. There are also procedures for staff to refer to about hygiene and infection control. Priory Close (3) DS0000025316.V287880.R01.S.doc Version 5.1 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): 32,33,34,35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There are sound polices and procedures in place to ensure that staff are safely recruited and vetted. There are in general sufficient numbers of staff to meet the needs of service users. Systems are in place to ensure that service users benefit from staff having regular supervision and guidance. Priory Close (3) DS0000025316.V287880.R01.S.doc Version 5.1 Page 20 EVIDENCE: The rotas for a 4-week period were examined. These indicated that there are two staff on duty from 8.00am until 8.00pm. At night there is a waking member of staff. Staff reported that 2 staff could take all 3 service users out with all 3 service users using the bus. Indeed on the day of inspection service users and staff were going out for lunch prior to an outpatient appointment. The inspector was unable to gain access to staff files on this unannounced inspection as the manager was on holiday. It has been previously reported that all staff have a POVA (Protection of Vulnerable Adults) and CRB (Criminal Records Bureau) clearance check and no new staff have commenced at this service since the last inspection. The inspector has spoken to the acting manager during the writing of this report and he confirmed that all staff files have all the information required under legislation. Staff reported that they have regular team meetings and one to one supervisions, which are documented. Further that they receive regular training from the organisation. Information provided by the manager via a questionnaire highlighted that 50 of the staff have had training to the level of NVQ 2 in caring for adults with a learning disability or the equivalent. Priory Close (3) DS0000025316.V287880.R01.S.doc Version 5.1 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): 37, 38, 39, 41,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The quality assurance systems and management approach ensure that the best interests of service users are supported. There are a some health and safety issues that the service will need to look at to ensure that service users are fully safeguarded. EVIDENCE: CSCI are currently processing an application for registered manager for this service. Staff reported that they found the manager to be approachable and supportive. The acting manager is currently undertaking an NVQ Level 4 in care and management. The Service Manager carries out an audit of service users’ health and welfare, accidents, risk assessments both personal and environmental, and staffing levels. A financial audit is conducted once a year by the parent company. There is an annual survey sent out to relatives of service users asking for their Priory Close (3) DS0000025316.V287880.R01.S.doc Version 5.1 Page 22 views of the home from Head Office. This provides service users and their relatives with an opportunity to influence the running of the home and to voice their opinions. There are policies and procedures to promote safe working practices. A sample of safety check records in relation to the gas, electric, portable appliances, fire alarm and emergency lighting tests and maintenance checks were examined and found to be in order. There was evidence that all staff had received fire safety training. Fire safety training is not being provided at frequencies recommended by the fire service of 6 monthly for day staff and 3 monthly for night staff. The inspector was informed that this is planned for the near future. It was noted that the last fire alarm test was undertaken on 10.03.06, the regularity of this must be increased in accordance with fire safety regulations. Fire equipment was check by a person qualified to do so in February 2006. There is also a fire risk assessment in place. Staff on duty were unable to locate a risk assessment for the use of a bed rail. This assessment should indicate whether the service user continues to need the bed rails and should note any changes to their needs. The assessment should be reviewed on a monthly basis. A copy of this risk assessment should now be forwarded to CSCI and staff should familiarise themselves with this document. As discussed earlier within this report service user files would benefit from further detailed information. Priory Close (3) DS0000025316.V287880.R01.S.doc Version 5.1 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 3 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 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 X 3 2 X Priory Close (3) DS0000025316.V287880.R01.S.doc Version 5.1 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 YA42 Regulation 23 Requirement The registered person must ensure that fire safety training is provided to day staff on a 6 monthly basis and night staff on a 3 monthly basis. The requirement remains outstanding from the previous inspection. The registered person must ensure that the kitchen floor covering is either repaired or replaced as it has started to lift in parts. The registered person must ensure that the mattress and bed frame is removed from the garden at the side of the house. The registered person must ensure that the carpets throughout the home are either cleaned or replaced as they have become stained in areas. The registered person must ensure that the fire alarm tests are increased in accordance with fire safety regulations. The registered person must ensure that the risk assessment relating to the use of bed rails is DS0000025316.V287880.R01.S.doc Timescale for action 10/08/06 2. YA24 23 10/08/06 3. YA24 23 31/07/06 4. YA24 23 31/08/06 5. YA24 23 31/07/06 6. YA42 23 10/08/06 Priory Close (3) Version 5.1 Page 25 reviewed on a monthly basis and staff must familiarise themselves with this document. A copy of the risk assessment must now be forwarded to CSCI RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 2. Refer to Standard YA3 Good Practice Recommendations Further written information around communication should be made available for staff to ensure that they and future staff can as far as possible communicate effectively with each service user. The registered person should consider the introduction of an independent advocate for the service user who does not have family members to act on their behalf. The registered person should consider amending the home’s complaint’s procedure so that it is more suited to their needs. The registered person should ensure the monthly evaluation plans in place for each service user, are regularly updated and they would also benefit from further detail. 4. YA5 6. YA22 7. YA7 Priory Close (3) DS0000025316.V287880.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Priory Close (3) DS0000025316.V287880.R01.S.doc Version 5.1 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!