CARE HOME ADULTS 18-65
Roman Court (1) 1 Roman Court Broadfields Pewsey Wiltshire SN9 5DS Lead Inspector
Elaine Barber Key Unannounced Inspection 12th July 2006 15:30 Roman Court (1) DS0000028114.V302956.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 Roman Court (1) DS0000028114.V302956.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. Roman Court (1) DS0000028114.V302956.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Roman Court (1) Address 1 Roman Court Broadfields Pewsey Wiltshire SN9 5DS 01672 564412 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) Steven@StevenAbbott.wanadoo.co.uk Mrs Jane Abbott Mrs Carol Bottoms Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Roman Court (1) DS0000028114.V302956.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 1st March 2006 Brief Description of the Service: Valued Lives is a private organisation, which operates five care homes for adults with a learning disability. All are small establishments, intended to offer a normal domestic lifestyle. The main lead for the organisation is taken by one of the registered persons, Mrs Jane Abbott. She is supported by other senior colleagues, including family members. Each of the Valued Lives homes is situated in Pewsey, or nearby small villages. Pewsey itself offers a range of amenities. The market towns of Marlborough or Devizes are within 15 minutes’ drive. Or, slightly further afield, there are the larger centres of Salisbury and Swindon. The organisation has a number of vehicles used to transport people, who contribute towards the costs of these. Most people now cared for by the organisation have been with them for a number of years. Time may have been spent in more than one of the homes that Valued Lives operates. Valued Lives also operates the Activity, Opportunity & Development centre (AOD). This is a day care facility which most of the organisation’s service users access, for at least part of each week. They pay a small weekly sum towards this. The unit is attached to the home in Ball Road, Pewsey. Roman Court is in Broadfields, Pewsey. The home cares for up to three people. Each person has a single room. There is an upstairs bathroom, and a separate toilet downstairs. There is also a living room, dining area and kitchen downstairs. There is an enclosed garden area at the back of the house. The current fees range from £636 to £745. Roman Court (1) DS0000028114.V302956.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection included two visits to the home on 12th and 13th July 2006. The visit on 12th July was unannounced. During the visits information was gathered using: • • • • Observation Discussion with people who lived in the home Discussion with staff Reading records. Other information and feedback about the home has been received and taken into account as part of this inspection: • • • The manager provided information prior to the inspection about the running of the home. The provider provided additional information after the visits to the home. A comment card was received from a relative. The judgements contained in this report have been made from all this evidence gathered during the inspection, including the visits. Feedback was given to the provider on 8th August 2006. What the service does well:
All the people at Roman Court had lived within Valued Lives for a number of years. They had therefore established their routines and their needs had been assessed over time to ensure that these needs were met. People had their abilities, needs and goals reflected in their individual plans to ensure that these needs were met. People could make choices and decisions in their daily lives. They chose the activities they followed, the colours of their rooms and living room and where to spend their time. People were supported to take risks as part of an independent lifestyle. Risks of day to day activities were assessed and unnecessary risks were minimised. The organisation provided in-house activities and was in the process of setting up a new activity centre. The people had chosen the activities they wished to pursue. There were also activities and trips in the local community such as shopping and the cinema. People were provided with a range of activities and opportunities to engage with their local community. Activities were suited to their individual needs and preferences.
Roman Court (1) DS0000028114.V302956.R01.S.doc Version 5.2 Page 6 People were able to maintain and develop appropriate relationships with family and friends. They kept in contact with different family members and families could visit any time. They also had friends from other houses in the organisation. People’s daily lives had an appropriate balance between necessary routines, and individual choice. They participated in the household chores and had a variety of outings. They assisted the staff with preparing meals and could make their own drinks and snacks. People were offered healthy, nutritious and enjoyable meals according to their individual needs and preferences. People received personal support in the way that they preferred and required. They had individual routines and records of their preferences. They had appointments with a range of health professionals, including the GP, dentist and optician to ensure that their emotional and physical health needs were being met. Medication was stored and recorded appropriately so that people were protected by the home’s policy and procedures for dealing with medication. People were safeguarded by the home’s policies and procedures for complaints. The relative who completed a comment knew how to make a complaint. There had been no complaints since the last inspection. There was information about the local multi-agency procedures and how to make a referral. Staff had received training about abuse. Staff helped people to manage their money and appropriate records were kept. People were protected from abuse, neglect and self harm. People lived in a comfortable, clean and safe environment, suitable to their needs. There were three bedrooms, a living room, kitchen and dining area. The accommodation was in the process of being redecorated and new windows were due to be fitted. People were supported by suitable numbers of appropriately trained and qualified staff. One member of staff was on duty at all times. There was a range of training and three out four staff had a National Vocational Qualification at level 3. One new member of staff had started work in the home since the last inspection. They had had all the appropriate checks before starting work so that people were protected by effective recruitment practices. The manager was appropriately qualified to run the home. She was supported by the owner and other senior managers in the organisation so that people were benefiting from a well run home. A quality assurance system had been developed and views of people who used the service, their relatives and visiting professionals had been obtained. People’s views underpinned all self-monitoring, review and development by the home. Roman Court (1) DS0000028114.V302956.R01.S.doc Version 5.2 Page 7 There was a range of health and safety measures to ensure that the environment was safe for the people who lived there and the staff. People’s health, safety and welfare were promoted and protected. 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. Roman Court (1) DS0000028114.V302956.R01.S.doc Version 5.2 Page 8 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 Roman Court (1) DS0000028114.V302956.R01.S.doc Version 5.2 Page 9 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): 2 Quality in this outcome area is good. This judgement has been made from evidence gathered during the visit to the home. People’s needs were assessed so that these needs could be met. EVIDENCE: There had been no recent admissions to the home. All the people at Roman Court had lived within Valued Lives for a number of years. They had therefore established their routines and their individual and varied needs had been assessed over time. There had also been continuity and stability in the staff team. Many had several years’ experience. This had given them a depth of knowledge regarding service users. Roman Court (1) DS0000028114.V302956.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area was good. This judgement has been made from evidence gathered during the visit to the home. People had their abilities, needs and goals reflected in their individual plans to ensure that these needs were met. People could make choices and decisions in their daily lives. People were supported to take risks as part of an independent lifestyle. Unnecessary risks were minimised. EVIDENCE: Each person had a very detailed care plan to meet all their individual assessed needs. However the plans were not signed or dated by a member of staff or the person concerned to show when they were developed and by whom. There was a recommendation at the previous inspection that all service user documentation should be clearly signed and dated. There was a sheet to record when reviews had taken place but these were not always completed when a review had occurred. Changes had been made to the care plans
Roman Court (1) DS0000028114.V302956.R01.S.doc Version 5.2 Page 11 following a review but these were not dated. There was no record of a review since July 2005. Care managers were not conducting annual reviews. The records showed examples of when people had made choices and decisions about their lives. Examples included choosing to spend time in their own rooms or the living room watching TV and choosing their daytime activities. Both people were busy stripping the wallpaper off their bedroom walls before redecorating them. They talked about choosing different activities at the new activity centre and choosing the colours for their bedroom walls. Each person had risk assessments for all aspects of their lives and these were signed and dated. These focused on promoting independence and included action taken to minimise risks. Roman Court (1) DS0000028114.V302956.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Quality in this outcome area was good. This judgement has been made from evidence gathered during the visit to the home. People were provided with a range of activities and opportunities to engage with their local community. Activities were suited to their individual needs and preferences. People were able to maintain and develop appropriate relationships with family and friends. People’s daily lives had an appropriate balance between necessary routines, and individual choice. People were offered healthy, nutritious and enjoyable meals, in line with individual needs and preferences. Roman Court (1) DS0000028114.V302956.R01.S.doc Version 5.2 Page 13 EVIDENCE: The daily records showed that people were participating in a range of activities including household chores and gardening. There were trips out to the garden centre, pub, café, shops, the hawk conservation trust and car rides. The records showed that there was a good mix of household chores and outings. People had chosen the new carpet for the living room. They chose to watch TV in the communal areas or spend time in their rooms. During the inspection people went for a shopping trip to Marlborough and a meal out in the afternoon. The people who lived in the home showed the inspector their rooms and the garden. They had grown their own plants in pots and were very proud of these. They were both stripping wallpaper off their bedroom walls before they were repainted. They said that they did their housework and washing and went to the shops. A new day service was being developed by the organisation. They said that they had visited the new building and had chosen the activities they would do when it opened. They said that they also went bowling, to the cinema, shopping, to the zoo and they went on holiday to a caravan owned by the organisation. They also said that they were going camping later in the summer. They were both interested in football and had recently had a three-day trip to the Liverpool and Manchester United football grounds. One person said that they saw their family once a month and had been on holiday to France with their family. The other said that they also saw their family and had visited their sister who lived abroad and were due to visit their mother who also lives abroad, in the autumn. They talked about meeting up with friends from other houses run by the organisation. One relative who completed a comment cards said that they were welcome in the home at any time and could visit their relative in private. There was a varied menu, which reflected a balanced diet. The people planned their own menus using recipe cards to choose different dishes. They helped the member of staff on duty to cook the evening meal and they could prepare their own drinks and snacks. One person required a special diet and this was catered for. Roman Court (1) DS0000028114.V302956.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area was good. This judgement has been made from evidence gathered during the visit to the home. People received personal support in the way that they preferred and required. People’s emotional and physical health needs were being met. People were protected by the home’s policy and procedures for dealing with medication. EVIDENCE: People were assisted with various levels of personal care and supervision depending on their individual abilities. People had established routines, such as their preferred time for getting up. Their daily routines were recorded in their care plans and daily notes. Assistance was given to choose clothes on a daily basis. Each individual had an allocated keyworker who organised shopping trips with people to purchase new items. Part of their responsibility was to ensure that people had sufficient clothes and toiletries. Roman Court (1) DS0000028114.V302956.R01.S.doc Version 5.2 Page 15 Valued Lives had a policy regarding any cross gender personal care. This provided suitable safeguards for both people who lived in the home and staff. There was a strong focus on health promotion and responding to any needs that arise. People received regular health monitoring including dental and optical check ups. Any specialised services, such as speech therapy or occupational therapy, were accessed as required. Visits to healthcare professionals were recorded including the GP, consultant, chiropodist, nurse, continence advisor, optician and dentist. All appointments are undertaken in private, although a staff member will give assistance as needed. There was a policy about medication. Medication was stored and recorded appropriately. Staff had received training in medication handling. There were records of medication received into the home and administered. A receipt was obtained when medication was returned to the pharmacist. Changes to medication were recorded and signed. A record was also made when a person took medication out of the home, for example when visiting relatives. There was a requirement at the last inspection that guidelines must be available for the use of as required medication to ensure that they are used within the prescriber’s instructions. This had been addressed and there was a new sheet in the front of the medication book explaining the rationale for as required medications. Roman Court (1) DS0000028114.V302956.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected 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 was good. This judgement has been made from evidence gathered during the visit to the home. People were safeguarded by the home’s policies and procedures for complaints and protection. People were protected from abuse, neglect and self harm. EVIDENCE: There was a complaints procedure including how to complain and the timescales for dealing with complaints. There had been no complaints made to the organisation and no complaints had been received by CSCI. The relative who completed a comment card knew how to make a complaint. There was a wide range of information about adult protection issues. This included details about multi-agency procedures within Wiltshire. A ‘Protection’ section in each individual’s care plan gave information about the various safeguards in place. These include recruitment checks, staff training, and key individual abilities and relationships that contribute to upholding someone’s welfare. Staff had received training about prevention of abuse. There had been no allegations of abuse. There was guidance about how to manage some behaviours which was developed with the involvement of the local community learning disability nurse. Physical interventions could be used with some people on occasions.
Roman Court (1) DS0000028114.V302956.R01.S.doc Version 5.2 Page 17 Individual guidelines described the holds, which may be used. received appropriate training in these techniques. Staff had Staff helped people to manage their money and appropriate records were kept. Roman Court (1) DS0000028114.V302956.R01.S.doc Version 5.2 Page 18 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, 30 Quality in this outcome area was good. This judgement has been made from evidence gathered during the visit to the home. People lived in a comfortable, clean and safe environment, suitable to their needs. EVIDENCE: Roman Court is a modern semi-detached house, in a residential estate in Pewsey. It is a short walk from the centre of the village, and all local amenities. The home is domestic in scale and in keeping with other houses in the street. It is attractively decorated and furnished. There was ongoing renovation, when required. As part of this process, all windows were due to be replaced. The home was in the process of being redecorated. On the day of the inspection the lounge was being wallpapered and a new carpet was due to laid. The people had chosen the colour. The two people were stripping the wallpaper off their bedroom walls with staff help. They said that they had chosen new colours for their rooms. There was a small dining and seating area next to the kitchen. The laundry facilities were domestic in style. There was a washing machine in the kitchen and a tumble drier in the garage. People said that they did their
Roman Court (1) DS0000028114.V302956.R01.S.doc Version 5.2 Page 19 own laundry. The home appeared clean and hygienic in all areas seen at this unannounced inspection. Roman Court (1) DS0000028114.V302956.R01.S.doc Version 5.2 Page 20 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 Quality in this outcome area was good. This judgement has been made from evidence gathered during the visit to the home. People were supported by suitable numbers of appropriately trained and qualified staff. People were protected by effective recruitment practices. EVIDENCE: Each home within Valued Lives had some staff specifically allocated to it. Cover was then made up by other staff, who worked in more than one setting. The owner’s aim was to employ sufficient people so that, even if they were one staff member down, there were still enough to cover all the organisation’s services without needing to rely on external agencies. Roman Court had three main staff who worked most of the shifts there and one person who provided additional cover. There was usually one person on duty. When service users went out to their planned activities, this person went with them. At nights, one person slept in. An on-call manager was available, if required. Two of the regular members of staff and the person who provided additional cover had a National Vocational Qualification (NVQ) at level three. The
Roman Court (1) DS0000028114.V302956.R01.S.doc Version 5.2 Page 21 training plan for the organisation was being updated. There was a range of training provided and staff kept their training up to date. All staff were to refresh all their basic training in November. There was one new member of staff who said that they had completed their induction training. They were booked to have all the basic training in November and they were due to start NVQ level 2 in September. The owners planned to introduce learning disability award framework training. There was a recruitment policy and procedure. One new member of staff had been recruited since the last inspection. The recruitment procedure had been followed. They had completed an application form and all the appropriate checks were carried out. Roman Court (1) DS0000028114.V302956.R01.S.doc Version 5.2 Page 22 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, 39, 42 Quality in this outcome area was good. This judgement has been made from evidence gathered during the visit to the home. The registered manager was suitably competent and experienced, and was supported by senior colleagues, so that service users benefited from a well run home. People’s views underpinned all self-monitoring, review and development by the home although the report about these views needs to be published. People’s health, safety and welfare were promoted and protected by the health and safety measures. EVIDENCE: The registered person for Valued Lives was Mrs Jane Abbott. She had lengthy experience of working with people with a learning disability, and had owned and operated her own services for many years. She was supported by other
Roman Court (1) DS0000028114.V302956.R01.S.doc Version 5.2 Page 23 senior staff within the organisation. Together, they oversaw all five services run by Valued Lives. The registered manager was Mrs Carol Bottoms. She had the registered managers award and kept her training up to date. Since the last inspection the registered person and registered manager had been working on their quality assurance for the service. The quality assurance framework was based on the systems in the house including policies and procedures, care plans, records and staffing. A consultant had provided advice and guidance about quality assurance. The views of people who used the service, relatives and visiting professionals had been collected. These had been collated into a quality assurance report for the whole service covering five homes. There was also a draft review report of the previous three years. Areas for improvement were identified. A copy of this report now needs to be sent to the Commission and made available to all people who use the service. There was a health and safety policy to comply with the relevant regulations. A number of general risk assessments and safe working procedures had been recorded. There were also individual risk assessments. There were arrangements for the training of staff in moving and handling, fire safety, first aid and food hygiene. A monthly ‘hazard’ inspection of the home was carried out. Hot water temperature regulators had been fitted to the taps. There were COSHH assessments, equipment was regularly serviced and portable appliances were tested annually. There was a fire risk assessment and records of fire safety checks. The radiators were not covered. Each person had an individual assessment of the risks posed by radiators which identified that they did not pose a risk. Information was available about what to do in the event of a heat wave. Roman Court (1) DS0000028114.V302956.R01.S.doc Version 5.2 Page 24 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Roman Court (1) DS0000028114.V302956.R01.S.doc Version 5.2 Page 25 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA39 Regulation 24 Requirement The registered person must supply to the Commission a copy of the report about the quality assurance survey and make a copy of the report available to service users. Timescale for action 30/09/06 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 YA6 YA41 YA6 YA41 YA6 YA41 Good Practice Recommendations Care plans should be signed and dated when they are developed. All changes to the care plans should also be signed and dated. The service user or their representative should sign the care plan to show they have been involved in developing their plan. Care plans should be reviewed at least every six months. A record of each review should be kept with the date. 2. 3. Roman Court (1) DS0000028114.V302956.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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