Inspection on 26/02/07 for Scope - Edward Street

This inspection was carried out on 26th February 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

Scope - Edward Street 22/02/06

Scope - Edward Street 04/11/05

Scope - Edward Street 04/03/05

Scope - Edward Street 03/08/04

Scope - Edward Street 08/03/04

Similar services:

Ruskin Lodge

Dystlegh Grange

The Good Companions

Springfield Cottage

Cuerden Grange Rest Home

Cornmill Nursing Home

Vitalise Sandpipers Centre

Sue Ryder Care Birchley Hall

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

CARE HOME ADULTS 18-65 Scope 1 and 3 Edward Street Widnes Cheshire WA8 0BW Lead Inspector Maureen Brown Key Unannounced Inspection 26 February 2007 09:20 Scope DS0000005178.V316843.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 Scope DS0000005178.V316843.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. Scope DS0000005178.V316843.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Scope Address 1 and 3 Edward Street Widnes Cheshire WA8 0BW 0151 420 3364 0151 420 3364 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) SCOPE Johanna Bunting Care Home 6 Category(ies) of Physical disability (6) registration, with number of places Scope DS0000005178.V316843.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 6 service users in the category of PD (Physical Disability). 22 February 2006 Date of last inspection Brief Description of the Service: 1-3 Edward Street is a purpose-built care home providing personal care and accommodation for six service users who have physical disabilities. The home is located in a residential area of Widnes and is within easy access of local amenities including shops, social and educational facilities. The premises consist of two bungalows (each accommodating three service users), which are managed by Scope. Each bungalow has three single bedrooms, a kitchen/dining area, lounge, bathroom, separate shower room and a utility room. There is an office that is linked by a door to one of the bungalows. There are also pleasant and accessible garden areas to the side and rear of the home that are fully accessible to service users. Limited car parking space is available at the home. Parking on the road outside the home is available. The staff team consists of the registered manager who is supported by thirteen care support workers. The fees at Edward Street are individualised and range from £39,015.00 to £53,915.00 per year. Optional extras include personal items, toiletries, newspapers, magazines, holidays and hairdressing. Scope DS0000005178.V316843.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit took place on 26 February 2007 and lasted seven hours. Maureen Brown carried out the visit. Feedback was carried out at the end of the visit with the registered manager. This visit was just one part of the inspection. Before the visit the home was also asked to complete a questionnaire to provide up to date information about them. Questionnaires were also made available for service users, relatives, staff and other professionals to find out their views. Other information since the last key inspection was also reviewed. During the visit various records were looked at and a tour of the home was undertaken. A number of service users and staff were also spoken with and they gave their views about the service. All the key standards were assessed and most were met. The previous requirements had been met. What the service does well: The home had an established staff team who were keen for high standards to be maintained at Edward Street. Residents’ plans of care and individual case notes were well documented and reflected each resident’s needs. Residents are actively involved in their care planning with support from the staff team. Relationships between residents and staff are good. Residents are able to approach staff for help with personal and other needs. The home provides sufficient numbers of staff to meet residents’ needs and there is always a senior person on duty. Staff are provided with an induction programme and ongoing training and development. Most of the staff had completed NVQ level II and one member of staff was working towards this. All staff had completed the mandatory training. The home provides a good variety of relevant training and staff said that the training was good. Meals were varied and reflected each person’s preference. They offered choice and variety and the menus were well balanced. Residents said that they complete the shopping list and therefore choose what they want to eat. Also residents assist staff in the purchase of food on a weekly basis. The home was clean and suitable and sufficient equipment is provided to meet the needs of the residents. The staff managed daily activities and entertainments well and provide a wide range of choice. Residents said they were pleased with the choices on offer. Scope DS0000005178.V316843.R01.S.doc Version 5.2 Page 6 Relatives stated on comment cards that they were satisfied with the overall care provided at Edward Street. Other comments included “we are always made welcome”, “the staff and service users seem to get on with each other very well” and “the home is always pleasant, clean and the residents seem happy”. Service users stated on comment cards that “the home is always fresh and clean”, “I always do what I want” and “staff clean on a daily basis”. Other comments included “staff always ask me what I want” and “good staff team”. What has improved since the last inspection? What they could do better: One area of the care plan records that should be improved is that the last entry on the old visiting professional sheet should be transferred to the new sheet for ease of reference. To ensure the service users have information that is accessible to them the Statement of Purpose and Service Users Guide should be considered in other formats. For the protection and promotion of the safety and welfare of the residents the minor damage to doorframes and corridor areas should be repaired. To ensure that information is easily accessible the staff files should be reorganised. Scope DS0000005178.V316843.R01.S.doc Version 5.2 Page 7 To ensure that all views are taken into account with regard to future planning of the home the quality assurance process should include visitors, family and stakeholders, be completed annually and the analysis shared. 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. Scope DS0000005178.V316843.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 Scope DS0000005178.V316843.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good information is provided for residents to make a decision about moving into the home. EVIDENCE: The home had a statement of purpose and service users guide, known as the service user delivery agreement within each service users file. These documents were written in plain English and available in standard, large print and audiotape formats. It was suggested that other formats be considered in line with service users needs. These documents contained all the information required for people to make a decision about moving into the home. Including general information about the home, a description of the facilities, the fees charged, a copy of the complaints procedure and the details of the registered provider, manager and staff. A copy of the most recent inspection report was available in the office and staff were aware of this. The pre-assessment document was available and the home uses a care profile, which covers all areas of personal care and daily living needs. It calculates Scope DS0000005178.V316843.R01.S.doc Version 5.2 Page 10 how many care hours are needed. The manager stated that social services also provide an assessment, which is used to assess if the service is suitable. Scope DS0000005178.V316843.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents’ health, personal and social care needs are met by the staff team who enable them to maintain their privacy and dignity. EVIDENCE: Two residents’ care records were seen during this visit. These were comprehensive and well presented in individual ring binders. Each contained sufficient information for staff to appropriately meet the needs of the residents. Monitoring sheets, 24-hour summary sheets, visiting professionals’ sheet and risk assessments were included in the care plans. The care plans were drawn up in consultation with the residents and family members and were based on their assessed needs and risks. Care plans were reviewed on a monthly basis, in conjunction with the residents. New visiting professional sheets had been placed into the care plans in line with the New-Year. It is recommended that the last record of the previous Scope DS0000005178.V316843.R01.S.doc Version 5.2 Page 12 year be transferred to the new sheet to enable ease of reference of information. Daily record sheets seen showed that day-to-day activities were recorded. This enabled staff and family members to see what a particular resident was undertaking during the day. They were written clearly, easy to follow and were signed by carers. The previous recommendation about avoiding abbreviations on daily record sheets has been met. Risk assessments were carried out for moving and handling, self-medication, preferred activities and other identified risks to the individual resident. Following a previous requirement these had been brought up to date and were now reviewed regularly. Service users are assisted when needed by staff in making decisions. Individual choices are recorded in the service users plan. Service users are assisted in managing their own finances and they request personal allowance as needed, with the manager overseeing the service users accounts. Scope DS0000005178.V316843.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ were able to take part in a range of activities. Personal and family relationships were encouraged by the home and the staff team supported people with this. EVIDENCE: The residents’ plans reflect the range of activities undertaken which included attending “lifestyles” day centre where a programme of crafts, music, information technology, working on an allotment, cooking or flower arranging is available. Each resident has three sessions a week. Other activities residents said they enjoyed included 10 pin bowling, watching TV and DVD/Videos, meals with friends, glass painting, church involvement, theatre and concert visits. Also music, singing, live shows, films and visiting family. Scope DS0000005178.V316843.R01.S.doc Version 5.2 Page 14 Residents spoken to said they enjoy going out and about in the community, to local shops, out for lunch, to the pub or cinema. The home has a wheelchairadapted vehicle, which all residents can access. Visits from family and friends were recorded in the care plans and case notes. Residents shared with the inspector the contact they had with family members and said they could choose to see visitors within their own room or in the shared lounge/dining area. Relatives also confirmed this in the comment cards received. Service users confirmed they have kept in touch with friends they had made from the past, where they used to live. Also service users have developed new personal relationships. During the inspection staff spoke to residents in a friendly manner, using residents preferred names. Consultation between the manager and the local college has been ongoing regarding suitable courses for the service users. Courses service users had wanted to attend were cancelled due to lack of participants. The manager is waiting for new dates. The college have said that they may provide a teacher at the home to work with service users there. Service users choose the meals they have each week. On a Sunday night a list is produced with service users and they purchase a variety of foods for the following week. A note of what each service user has eaten and drunk is kept in the diary. It was noted that a variety of meat, fish, cheese, eggs etc were used. The weekly shopping list was seen on the notice board ready for shopping the day after this visit. Scope DS0000005178.V316843.R01.S.doc Version 5.2 Page 15 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. The residents’ health, personal and social care needs are met by the staff team who enable them to maintain their privacy and dignity. EVIDENCE: The sample 24-hour summary records seen described how the residents preferred to be supported in their daily routines. Times for rising and retiring, preferred moving and handling techniques and personal care preferences were recorded, as was choice of clothing and hairstyle. All residents were dressed differently according to their own choice. Residents tended to visit GP’s, chiropodists, opticians and dentists in the local community. These professionals would visit the home on request. Appointments with consultants and other hospital appointments were also undertaken. Records were kept of all these visits and they were up to date. Staff said that they supported residents on these visits. New visiting professional sheets had been put onto residents’ files and the transfer of the last entry should be made from the old to the new sheet. A previous Scope DS0000005178.V316843.R01.S.doc Version 5.2 Page 16 recommendation to transfer the last date of each visit to the new sheets so that last visits were noted had not been addressed. The recommendation remains. However, during this visit the process of transferring this information had begun to be completed. Homely remedy sheets were seen in each service users plan and these had been signed by GPs. The home uses a Monitored Dosage System supplied by a local chemist. It is kept in a secure cupboard in the bathroom. Medication Administration Record sheets seen were and appropriately completed. No Controlled drugs are kept at the home at this time but appropriate storage is available should this be needed. Most staff had received medication training. Three staff are due to undertake training in the near future. All staff have completed medication awareness training at the home prior to administering medication. Scope DS0000005178.V316843.R01.S.doc Version 5.2 Page 17 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. Residents and relatives were satisfied with the support they received from the manager and staff. Clear policies and procedures were in place to ensure that residents were protected from abuse, neglect and self-harm. EVIDENCE: The complaints procedure was see in the statement of purpose and in each service users file. It includes timescales for action and the Commissions details. The home has a complaint form that would be used. The Commission or the home had received no complaints since the previous visit. Relatives confirmed they were aware of the complaints procedure at Edward Court. The home had Halton’s local authority “no secrets” policy available and the manager confirmed that they would follow these guidelines in the event of an alleged or suspected case of abuse. During discussions she was clearly able to demonstrate the process she would undertake in line with the “no secrets” guidance. The homes policy on protecting adults from abuse included information about reducing the risk, types of abuse and what to do in the event of witnessing abuse. All staff have undertaken Scopes and the Local Authority training on Protection Of Vulnerable Adults. Other policies available include adult protection, bullying, harassment and whistle blowing. Scope DS0000005178.V316843.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a clean and comfortable environment for the people to live in. EVIDENCE: Both bungalows were visited during this inspection. Each was furnished in a domestic style with additional equipment such as hoists and tracking provided as necessary to meet the residents’ needs. Residents said that bedrooms were decorated to their preferred style and staff stated that shared lounge and dining areas were decorated with residents’ involvement in the colour scheme chosen. Each bungalow was clean, tidy and free from any unpleasant smells. Scope DS0000005178.V316843.R01.S.doc Version 5.2 Page 19 Generally the décor in the communal areas was good, however it was suggested that the slight damage to walls and doorframes from wheelchairs be attended to. Four bedrooms are currently being stripped ready for redecoration over the next two weeks. One bedroom had been redecorated since the last visit. Flooring in the bathroom had also been replaced. The kitchen was noted to be clean and a new system has been adopted for fridge and freezer temperatures. This is produced by the Food Standards Agency and has review sheets each month. It appears to be a good system to use. Scope DS0000005178.V316843.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 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. Service users are protected by the homes recruitment policy and practices as they are consistently followed. EVIDENCE: At the time of this inspection the agreed staffing levels were met. The staff team consists of the registered manager and thirteen care support workers support her. Eight of thirteen staff had obtained NVQ level II in Care. The manager said one staff member was currently undertaking NVQ II. The manager has completed the Registered Managers Award. Mandatory training includes first aid, moving and handling, food hygiene, health and safety, Cerebral Palsy awareness, fire prevention, adult protection and medication. Specialist training includes Cerebral Palsy awareness and safe clamping in the van. Scope DS0000005178.V316843.R01.S.doc Version 5.2 Page 21 Staff meetings are held on a regular basis. The last senior support staff meeting was held on 13.10.06. 3 staff attended. Issues discussed included service users, staff, supervision and Any Other Business. The previous meeting was held on 18.8.06. The last general staff meeting was held on 14.02.07 with five staff attending. Issues discussed included mobile phones, service users holidays, sleep-ins, outings, paperwork, keys, medication and any other business. The recruitment procedure followed ensured that all the staff employed were suitable to work with vulnerable people. Three staff files were examined and these showed that pre-employment checks were carried out. Amongst the documentation available were application forms, two references and Criminal Record Bureau checks. All staff had completed a medical questionnaire. Copies of supervision notes, appraisals and certificates of courses undertaken were also available. The files were up to date and it was suggested that files be reorganised to assist in access to information. Formal supervision was undertaken on a regular basis. This was up to date with records kept. Annual appraisals were completed with records available. All staff had supervision sessions during January or February 2007. All staff had received an appraisal in July or August 2006. The previous requirement regarding supervision had been met. Scope DS0000005178.V316843.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health, safety and welfare of the service users are protected. The views of service users are obtained and influence the running of the home. EVIDENCE: The registered manager has worked for Scope for thirteen years, twelve of which for Edward Street and four years as manager. She has completed the Registered Managers award, NVQ assessor and Designated Adult Protection Advisor. She has completed other courses to update her skills and knowledge base. The service users survey was completed in February 2007 and 4 service users had so far completed this. The manager has designed a new questionnaire as Scope DS0000005178.V316843.R01.S.doc Version 5.2 Page 23 she considered the previous one not to be user friendly. The new one has “faces” for the answer section for example “happy, ok, unhappy”. This is much improved on the previous format. Visitor and family surveys are sent out periodically. The manager stated that other stakeholders are generally not contacted. She stated that the home needed a robust Quality Assurance procedure in place. It was suggested that all surveys be conducted at the same time and that stakeholders should be included. Also that analysis of these be completed and shared. Meetings are held regularly with the service users each month. The last one was on 1.02.07 with all six service users. Issues discussed included New Year, Lifestyles, holidays, days out, thanks, swimming and any other business. Safe working practices include fire safety in which all weekly checks are carried out and recorded, up to date certificates for gas safety, electrical safety and Portable Appliance Tests were available. Tests and servicing for all equipment for moving and handling had been completed. Previous requirements regarding Portable Appliance Tests and electrical safety had been addressed. Hoists and beds are serviced annually. Electric wheelchairs are repaired as necessary. The fire book was seen and weekly fire system checks were completed, monthly emergency lighting tests, and full fire evacuation completed in February 2007 with five staff. The accident book was seen and records were appropriate and filed in each service users file. Scope DS0000005178.V316843.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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Scope DS0000005178.V316843.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. 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 2 3 4 5 Refer to Standard YA1 YA19 YA24 YA34 YA39 Good Practice Recommendations The registered person should ensure that the Statement of Purpose and Service Users Guide should be considered in other formats suitable for service users needs. The registered person should ensure that the last entry on the old visiting professional sheet is carried forward to the new sheet for ease of reference. The registered person should ensure that the slight damage to walls and doorframes is attended to. The registered person should ensure that staff files are reorganised to aid use. The registered person should ensure that surveys are all be completed annually and the analysis shared. Scope DS0000005178.V316843.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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 Scope DS0000005178.V316843.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. 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