Inspection on 08/05/07 for Queensberry Road

This inspection was carried out on 8th May 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

Queensberry Road 23/01/06

Queensberry Road 30/06/05

Queensberry Road 11/01/05

Queensberry Road 07/06/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Queensberry Road 22 Queensberry Road Kettering Northants NN15 7HL Lead Inspector Linda Clarke Key Unannounced Inspection 8th May 2007 07:30 Queensberry Road DS0000012891.V336258.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Queensberry Road DS0000012891.V336258.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. Queensberry Road DS0000012891.V336258.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Queensberry Road Address 22 Queensberry Road Kettering Northants NN15 7HL 01536 415201 F/P 01536 415201 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) Royal Mencap Society Mrs Lesley Anita Fagg Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Queensberry Road DS0000012891.V336258.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No one falling within category LD may be admitted into 22 Queensberry Road when there are 5 persons of category LD already accommodated within this home The maximum number of persons to be accommodated at 22 Queensberry Road is 5 23rd January 2006 Date of last inspection Brief Description of the Service: 22 Queensbury Road is a care home providing personal care and accommodation for up to 5 persons with a Learning Disability. The five single bedrooms are without en-suite facilities, two bedrooms being located on the ground floor, with the remaining three bedrooms being located on the first floor. In addition the ground floor provides a large open plan lounge, dining and kitchen area, a utility room and walk-in shower, whilst the first floor provides a bathroom and office. The first floor being accessible via a stairwell. The front door has a level access provided by a ramp, whilst the rear garden has a patio area, large area laid to lawn and benefits from mature plants and shrubs. Information is located on site detailing the range of services offered, which includes the Statement of Purpose and a copy of the Commission for Social Care Inspections, Inspection Reports, which are located in the office. Fees payable are dependent upon an assessment undertaken by Care Management, which will determine the level of contribution payable by the service user. There are additional costs payable for activities and purchasing of personal items. Queensberry Road DS0000012891.V336258.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection process consisted of pre-planning the inspection, which included viewing the previous Inspection Report, reviewing of the pre-inspection questionnaire, and Comment Cards sent to service users by the Commission for Social Care Inspection, five service user Comment Cards were returned. The unannounced site visit commenced on the 8th May 2007 and lasted 1 day. The focus of the inspection is based upon the outcomes for the service users. The method of inspection was ‘case tracking’. This involved identifying service users with varying levels of care needs and looking at how these are being met by the staff at Queensbury Road. Three service users were selected as part of the case tracking and discussions were held with all of them, the level of the discussion was dependent upon the abilities of the service user. The method of case tracking included the review of service users’ individual care records, discussions with staff of various delegated responsibilities within the home and reviewing the records, training records and the minutes of service user and team meetings. Comments incorporated within Service User Comment Cards included: • I want to stop here. Responses to questions indicated that service users were happy with the care they receive, and that they are supported to make decisions and have an active part within the community engaging in recreational and leisure activities. Service users felt that they were treated well, and were confident in knowing how to raise concerns. Staff supported service users in completing the comment cards. What the service does well: Service users benefit by being supported by care staff that have a clear understanding of their needs, and receive the appropriate training to support service users. Staff encourage service users to express their views, and positive and supportive relationships between service users and staff exist, promoting service user welfare. Service users records are detailed and emphasise service user strengths, preferences, expectations and goals, documentation identifies the level of support service users require and the manner in which they wish to be supported, this ensures service users receive individual and tailored care. Service users are supported to make decisions, and are supported when those decisions may have a risk, promoting independence and choices. Queensberry Road DS0000012891.V336258.R01.S.doc Version 5.2 Page 6 Service users experience a lifestyle, which they have chosen, accessing a wide variety of leisure and recreational pursuits, supported by dedicated staff that work flexibly to offer the appropriate support. 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. Queensberry Road DS0000012891.V336258.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 Queensberry Road DS0000012891.V336258.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, 3 and 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are provided with information detailing the services offered by Queensbury Road, with service users benefiting from a written contract. EVIDENCE: Service users have access to a Statement of Purpose, which outlines the role of the care home, providing additional information as to the services offered, the accommodation and information on policies and procedures. The Statement of Purpose has not been reviewed for a while and therefore cannot be relied upon for its accuracy. The document is produced in a written format and is not appropriate to the needs of service users currently residing within the home. Service users would benefit from documentation being presented in a format appropriate to their needs, such as audio version or a written format incorporating symbols and photographs. The Registered Manager said it is her intention for it to be reviewed. Queensberry Road DS0000012891.V336258.R01.S.doc Version 5.2 Page 9 Service users currently living at Queensbury Road have done so for sometime; the Registered Manager confirmed that if a vacancy were to become available then a representative of Social Services would undertake an assessment of the individuals care needs. Comment cards completed by service users prior to the site visit reflected that a majority of service users were asked if they wished to move into the home. Service users have a Tenancy Agreement through a housing association, detailing the terms and conditions of their residency, including their financial contribution, which is dependent upon the benefits they receive, additional costs, are met by Mencap. Queensberry Road DS0000012891.V336258.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, 8 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users independence is promoted, and they are supported to make decisions affecting all aspects of their lives with service users receiving a wide range of activities and recreational pursuits that have a direct impact on the quality of care they receive, and their lifestyle. EVIDENCE: The care plans of three service users were viewed, two of which had a specific diagnosis, which contributed to their learning disability. The care plans gave information where appropriate as to how the disability of the service user affected their day-to-day lives, and the nature of the support the service user required, in order to lead the lifestyle of their choice. The care plans are written from the service users perspective and reflect their wishes and preferences, and detail their preferred daily living routines, such as time of getting up, whether they wish to eat breakfast before or after having a Queensberry Road DS0000012891.V336258.R01.S.doc Version 5.2 Page 11 shower, their evening occupation and activities including information as to how these choices are to be supported. This process ensures that the care service users receive is reflective of their decisions and choices. The introduction of Person Centred Plans would enable service users to have a greater awareness of the contents of their care plans, by incorporating signs, symbols and photographs to support the written information. Person Centred Plans should also contain the goals and aspirations of service users, which are regularly reviewed upon their achievement. The Registered Manager advised that she herself has undertaken training in the development of Person Centred Plans, which will be cascaded to all care staff. Staff spoken with were aware of Person Centred Plans and that these would be introduced when they had received the appropriate training. Comment cards completed by service users prior to the site visit reveal that in the main they feel that they make decisions about what they do each day. Weekly records of the three service users case tracked were viewed, information within the weekly log records service user day to day lives, these are laminated and service users keep these in their bedroom. Care Plans are supported by risk assessments, which support service users to take risks as part of their lifestyle choices, areas which were risk assessed including, personal care, accessing transport, attending activities and household tasks. Service users participate in a forum, which is open to all service users residing with Mencap care homes in the locality, currently these are chaired by members of staff, but the intention is for service users to run these independently from staff. Staff demonstrated through their conversation and interaction with service users, a clear understanding of their role in offering support and guidance, and awareness as to the rights of service users to express opinions and make decisions, service users have a wide range of communication needs, all of which are met by staff. Queensberry Road DS0000012891.V336258.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, 14, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users enjoy, experience and participate in different activities of interests and are supported to maintain their preferred individual daily routines and choice of lifestyle with the support of the staff. EVIDENCE: On the day of the site visit service users all had a day off following the Bank Holiday; upon arrival all but one service user was still in bed. Service users got up on in their own time and on their own initiative walking into the communal areas for a cup of tea and breakfast. Service users and staff interacted in a relaxed manner. Weekly records detailed the range of activities which service users participate in these collectively included eating out at a variety of places including pubs, fast food outlets and cafeterias. Recreational outings included visits to Queensberry Road DS0000012891.V336258.R01.S.doc Version 5.2 Page 13 Hunstanton, Pitsford Reservoir, Irchester Country Park and Twycross Zoo. Other recreational pursuits included shopping, bowling, and swimming. The comment cards completed by service users recorded the following the comments: • • • • I like shopping and Church. I stay at home on Tuesdays and Thursday, I go to pantomimes, watching swimming and go out for a meal. I like to buy roses and flowers, and go to discos and dance. Like to go swimming on Saturdays, and to a disco on Thursdays. I would like to go to Blackpool. On the day of the site visit service users spoke of their recent trip to Twycross Zoo, service users showed the souvenirs they had purchased, service users excitement of the trip was evident and it was clear that they had enjoyed the trip, and were able to remember the animals which they particularly enjoyed seeing. All service users have planned their holiday for this year, and include two destinations, Blackpool and the Norfolk Broads accompanied by staff. On the day of the site visit two relatives visited a service user, all going out for lunch, one of the relatives stated that they visit regularly and are always made to feel welcome. The weekly records and care plans showed that service users have contact with family and friends; one service user making regular overnight visits to their family at weekends. Service users do not require specialist diets at present, food is kept secure due to the medical conditions and needs of some service users, staff support service users in the preparation of meals the level of support required is detailed within service user care plans. Service users meet weekly to discuss the menu for the following week, and are supported by staff to shop at the local supermarket. Queensberry Road DS0000012891.V336258.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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service user health care needs and independence is promoted by receiving timely care and support provided in the preferred way. EVIDENCE: The personal support individual service users require is detailed within their care plan; information recorded includes hairstyle choices, clothing preferences, the location of their toiletries and preferred daily routines. The home does provide a walk-in shower on the ground floor, for those service users who are unable to use the stairwell. Records confirmed that service users benefit from a range of health care services, which include dentists, general practitioners, learning disability nursing services, podiatrist and opticians. Documentation details the level of support service users require in accessing health care including the issues relating to medication. All staff responsible for the administration of medication undertake training. Queensberry Road DS0000012891.V336258.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by a complaints procedure and by staff trained in safe guarding adult processes. EVIDENCE: Documentation submitted by the Registered Manager prior to the site visit detailed that their have been no complaints with regards to the service, the Commission for Social Care Inspection has equally not received any concerns or complaints since the last Inspection. The Registered Manager advised that at a recent service user forum it was highlighted that some service users do not know how to complain or whom they should speak with, the comment cards received by the Commission for Social Care Inspection supports this, the service user comment cards however reflected that carers do listen and act upon what they say. The Registered Manager advised that care staff would be speaking with service users to ensure that they know whom to speak too. Observations between service users and staff were open, and issues of concern, which affect service user day-to-day lives, are dealt with as they arise. Queensberry Road DS0000012891.V336258.R01.S.doc Version 5.2 Page 16 Staff spoken with during the site visit confirmed they had received training in safeguarding adult protocols, and training records details staff attendance at the training, the training enables staff to recognise and respond to allegations or suspicion of abuse, policies and procedures developed by the Local Authority and Mencap offer guidance and support to service users and staff. Queensberry Road DS0000012891.V336258.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, 26 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with a warm, safe, clean, comfortable and wellmaintained environment suitable for their needs. EVIDENCE: Queensbury Road is a detached house, set within a residential area and benefits from local services and amenities; access to the ground floor via the front is via a level access ramp, which leads into the hallway. The ground floor has a large open plan lounge, dining and kitchen area, two bedrooms and a utility room leading into a walk-in shower room. Access to the first floor is via the stairwell, where three bedrooms, a bathroom and office, are located. Furniture and fittings are in good decorative order, new leather sofas and chairs have been ordered for the lounge, and service users are awaiting their delivery. One service user on the day of the site visit was going out in the afternoon accompanied by a member of staff to shop for bed linen; this is part Queensberry Road DS0000012891.V336258.R01.S.doc Version 5.2 Page 18 of the re-decoration of the bedroom. Two of the bedrooms were viewed, and were very large in size and were decorated to a good standard with colour and styles being chosen by the service user. Comment cards completed by service users prior to the site visit reflected that the home is fresh and clean. Additional comments within the comment card included: • I like living here and don’t want to move, I like my bedroom. Service users Care plans detail information about the laundering of their clothing, and the level of support required, the home provides a variety of domestic appliances, which include a dishwasher, washing machine and tumble dryer. Queensberry Road DS0000012891.V336258.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, 33, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient numbers of trained staff are recruited through a robust recruitment process ensuring that service user care and social needs are individually, collectively and safely met. EVIDENCE: Eight members of care staff along with the Registered Manager support the service users; four members of care staff have attained a National Vocational Qualification. The staffing rota details that two members of staff are on duty during the day, with one member of staff sleeping on the premises overnight. The hours worked by staff are flexible to facilitate service users engaging in recreational and leisure pursuits. Staff said that they attend regular team meetings, which provide an opportunity for staff to discuss issues relating to service users and the day-toQueensberry Road DS0000012891.V336258.R01.S.doc Version 5.2 Page 20 day running of the home. In addition staff have the opportunity to participate in a staff forum, which is held across the Mencap Eastern Region. The quality assurance process completed by Mencap recorded that staff records reflect the necessary documentation with regards to the recruitment of staff, which includes a Criminal Record Bureau check. Staff spoken with confirmed the training they receive, as did the training records viewed, training included health and safety, first aid, food hygiene, report writing, equality and diversity, safeguarding from abuse, supporting behaviour, and medication to name some, the training enables staff to offer the appropriate support and care for service users, ensuring service users lead an active and fulfilling life in line with their wishes and expectations. Staff confirmed that they receive regular one to one supervisions, which are recorded; the quality assurance process conducted by Mencap also confirmed this. Queensberry Road DS0000012891.V336258.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager offers a clear sense of leadership, ensuring service user health; safety and welfare are promoted. Service users are provided with opportunities to comment on and affect the service they receive. EVIDENCE: The Registered Manager, Lesley Fagg has been the Registered Manager of Queensbury Road since November 2006 and is currently working towards the Registered Managers Award. Mencap operates an annual quality assurance process, which includes sending out questionnaires and surveys to all its service users, the documentation is produced in large print supported by pictures and symbols for the benefit of its audience. The Registered Manager advised that the results of these surveys Queensberry Road DS0000012891.V336258.R01.S.doc Version 5.2 Page 22 are collated, and any action required is taken. The Registered Manager however stated that the results of the survey are not published for the benefit of service users, but are discussed with them as appropriate. It is recommended that service users should have the option of viewing the outcome of the quality assurance process including a plan of any action Mencap intend to take; this should be produced in a format appropriate to the needs of service users. It is further recommended that the quality assurance process includes seeking the views of service user relatives/friends and those providing support such as health and social care professionals, and the results are included within the final document produced, and made available to all participants. As part of the quality assurance process, the Registered Manager on a monthly basis is visited by her line manager, who reviews documentation, speaks with service users and staff, following the visit a report is produced of the findings detailing any actions which the Registered Manager or Mencap as an organisation has to address. In addition service users participate in weekly meetings and forums with other Mencap residential care homes in the area. The meeting and forums provide service users with an opportunity to meet and discuss issues, which affect them, and provides an opportunity to mix with other individuals in a similar situation. The Pre Inspection Questionnaire submitted prior to the CSCI prior to the site visit detailed the regular maintenance of health and safety systems within the home, including fire systems and equipment, environmental health visits, central heating systems and emergency call systems. Records detailing fire drills and checks were viewed, and found tests to be carried out on a regular basis; additionally service user daily notes reflected their involvement in fire drills. Queensberry Road DS0000012891.V336258.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 2 2 3 3 3 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 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 2 3 3 3 X LIFESTYLES Standard No Score 11 X 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 X 3 X 2 X X 3 X Queensberry Road DS0000012891.V336258.R01.S.doc Version 5.2 Page 24 None 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 YA1 Good Practice Recommendations Prospective and current service users may benefit from documentation about Queensbury Road including photographs and additional signs and symbols for ease of reference. Service users would benefit from the introduction of Person Centred Plans, which detail all aspects of their care including their goals and aspirations. The Person Centred Plans should be produced in a format, which the service user understands, so that they can be fully involved. It is recommended that the results of the quality assurance system along with any action to be taken by Mencap as a result of the survey is produced and distributed to service users and is published in an appropriate manner format reflective of service users needs. 2 YA6 3 YA39 Queensberry Road DS0000012891.V336258.R01.S.doc Version 5.2 Page 25 4 YA39 It is recommended that the quality assurance process be increased to include seeking the views of service user relatives and friends and those involved in their care such as health and social care professionals, with a report of the findings being made available to the participants. Queensberry Road DS0000012891.V336258.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Queensberry Road DS0000012891.V336258.R01.S.doc Version 5.2 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. 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