CARE HOME ADULTS 18-65
Speakers Court St James`s Road Croydon Surrey CR0 2AU Lead Inspector
Lee Willis Unannounced Inspection 31 January 2006 09:50
st Speakers Court DS0000025838.V274215.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Speakers Court DS0000025838.V274215.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Speakers Court DS0000025838.V274215.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Speakers Court Address St James`s Road Croydon Surrey CR0 2AU 020 8665 0745 020 8665 0745 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 Laura Ainslie Care Home 7 Category(ies) of Physical disability (7) registration, with number of places Speakers Court DS0000025838.V274215.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. A variation has been granted to allow two specified service users aged 65 or over to be accommodated. 16th September 2005 Date of last inspection Brief Description of the Service: Speakers Court is owned by Croydon Churchs Housing Association, and managed and staffed by the registered charity - Scope. The project is registered with the Commission for Social Care and Inspection to provide accommodation and personal support for up to seven younger (18-65) adults with Cerebral Palsy and a broad range of associated physical disabilities. At present the vast majority of the occupants currently residing at Speakers Court are aged in their early sixties and over. Laura Ainslie has recently undergone a ‘fit’ person interview with the Commission and is now the registered manager of the project. Speakers Court is attached to St James church and is in keeping with the style of the surrounding architecture. Situated around an enclosed courtyard these five purpose built flats are all self-contained and have there own front doors, open plan lounges/kitchen areas, bedrooms, and en-suite toilet and bathing facilities. All the flats are wheelchair accessible and have been provided with suitable environmental adaptations and disability equipment to meet the individually assessed needs of the occupants. There is also a separate office/sleep-in room, kitchen and toilet for staff use. Located relatively close to the centre of Croydon the flats are well served by a wide variety of local shops, cafes, and leisure facilities. The Project is also on a main line bus route and is reasonably close to East Croydon train station and the new tram service, providing Speakers Court with excellent links to central Croydon, London and the surrounding areas. Speakers Court DS0000025838.V274215.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and began at 9.50 on the morning of 31st January 2006. It took two and three quarter hours to complete. Since the projects last inspection, which took place in September 2005, the Commission has not received any more comment cards in respect of this service. The majority of this inspection was spent talking to the senior carer in-charge of the early shift, three out of four of the occupants who were at home, and the two other members of staff who were on duty at the time. The rest of this inspection was spent examining the projects records and touring the premises. No additional visits or complaints investigations have been carried out by the CSCI in respect of this service in the past twelve months. What the service does well: What has improved since the last inspection?
The project has managed to meet all the requirements identified in its last inspection report within the prescribed timescales for action. Important areas of practice that have improved since September 2005 include: Speakers Court DS0000025838.V274215.R01.S.doc Version 5.1 Page 6 The projects more flexible approach to arranging staffing levels, which are now far more centred on the needs and wishes of the occupants. The manager now ensures that an additional third member of staff works at least three early shifts a week to cover so called ‘peak’ periods of activity. Arrangements for assessing and managing identified risks, including the risks associated with occupants self medicating, have improved. All the projects water outlets have recently been checked by a suitably qualified engineer and where appropriate fitted with thermostatic mixer valves to ensure hot water never exceeds 43 degrees Celsius, in accordance with health and safety guidelines. New shower facilities have also been installed in three of the flats. Furthermore, all the occupants and staff met were confident that Scope had agreed a time specific plan of action with the Housing Association responsible for maintaining the premises to begin refurbishing and decorating all the flats in April 2006. Finally, since the projects last inspection sufficient numbers of the current staff team have now either attended or arrangements made for them to receive suitable training in recognising, preventing and reporting abuse. What they could do better:
The positive comments made above notwithstanding their remains some key areas of practice that could to be improved, including: The projects Statement of purpose needs to be up dated to reflect all the significant changes that have occurred in the past twelve months, including the new name, experience and qualifications of the manager. Care plans, although adequate, the format could be improved to make it far more person centred, setting out in detail the personal goals each occupant hopes to achieve. One of the occupants mobile hoists has been out of action for a considerable amount of time and the arrangements the project has with external agencies for the maintenance of this essential piece of equipment needs to be reviewed as a matter of urgency. Since this piece of equipment has been out of action order one occupant has been unable to take a bath for over a month. The delay in repairing the hoist is unacceptable to the occupant, Scope and the CSCI. All the senior staff who are formally supervising their colleagues must receive appropriate training to carry out this task. The results of any survey and/or questionnaire undertaken by the project in order to ascertain the views of the occupants and other major stakeholders Speakers Court DS0000025838.V274215.R01.S.doc Version 5.1 Page 7 should be published and form the basis of an effective self-monitoring quality assurance system. Finally, although the projects health and safety arrangements are in the main sufficiently robust to ensure the occupants live in a reasonably safe environment the fire risk assessment for the building needs to be reviewed at more regular intervals (i.e. At least annually) and where appropriate, up dated. 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. Speakers Court DS0000025838.V274215.R01.S.doc Version 5.1 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 Speakers Court DS0000025838.V274215.R01.S.doc Version 5.1 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): 1&2 Overall, the project ensures prospective new occupants and their representatives have all the information they need to make an informed decision about whether or not to move in, although its Statement of purpose needs up dating to reflect recent changes at the project. EVIDENCE: The staff member in charge of the early shift was able to locate a copy of the projects Statement of purpose, which was last reviewed in January 2005. The document was written in plain language and contained all the information required by the Care Homes Regulations (2001). The projects Statement of purpose needs to be reviewed and up dated accordingly to reflect all the changes that have occurred at the project in the past twelve months, which has included the appointment of a new manager. The project remains fully occupied and there have been no new admissions since September 2005, when the project was last inspected. Speakers Court DS0000025838.V274215.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Care plans accurately reflect occupant’s personal, social and health care needs, although it is recommended that a far more person centred approach to care planning is introduced to ensure staff have all the information they require to plan for and meet the occupants needs. Furthermore, the projects arrangements for assessing and managing identified risks ensures the occupants are actively encouraged and supported to live, so far as reasonably practical, independent life’s. EVIDENCE: It was evident from the three care plans sampled at random that they are all based on assessments of each occupant’s personal, social and health care needs. During the course of the projects last inspection, the new manager said although the existing care plan format had been used to great affect in the past, there was room for improvement. The member of staff in charge of the early shift said they were not aware of any recent amendments made to the care plan format and in the absence of the projects registered manager it was decided it would be better to discuss the matter at a later date. Consequently, the recommendation made in the projects last inspection report regarding the
Speakers Court DS0000025838.V274215.R01.S.doc Version 5.1 Page 11 introduction of a more person centred care plan format has merely been repeated in this one, and is not considered unmet. One occupant spoken with at length said the project has regular meetings, which tend to be well attended by the occupants. A couple of other occupants met said overall, staff are very good listeners and always take into account their wishes and feelings. These two individuals went onto to say that staff actively encourage you to make informed decisions about you life, including what you eat and what activities you participate in. All the occupants currently residing at Speakers Court are actively encouraged to maintain their financial independence and look after their own financial affairs. One occupant said staff are always on hand to advise them about financial matters and budgeting. They went onto to say that they keep any money they have withdrawn from their account in a secure place in their flat. Having inspected three occupants care plans at random it was positively noted that a number of risk assessments covering various aspects of these individuals personal, social and health care needs, including the action to be taken to minimise any identified risk and/or hazard, had been undertaken by staff working at the project. For example, one file contained guidance for staff to follow to minimise identified risks associated with an occupant bathing and self-medicating. Speakers Court DS0000025838.V274215.R01.S.doc Version 5.1 Page 12 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 14, 15 & 16 The project ensures the occupants have every opportunity to pursue their own social, leisure and educational interests both at home and in the wider community. EVIDENCE: The shift leader said half the occupants choose to regularly attend services at a couple of churches in the area, which cater for their specific Christian denominations. The occupants travel to church independently and information about individuals spiritual needs is contained in their care plans. All three of the occupants spoken with at length said one of the best things about living at Speakers Court was having the freedom to pursue your own social interests and hobbies when you wanted. One occupant spoken with at length said a part-time member of staff was helping him build up his stamina and they were now both going swimming at a local baths once a week. He went on to say that he had been very busy over the Christmas period and had been to the cinema, the theatre and helped cook Sunday dinner for a friend and their family. Another occupant who gave their permission to talk to them
Speakers Court DS0000025838.V274215.R01.S.doc Version 5.1 Page 13 in their flat was busy on their home computer. They said the best thing about living at Speakers Court was having your own front door, which you could close when you wanted. All three occupants met said they were not aware of any restrictions of visiting times for family and friends. Speakers Court DS0000025838.V274215.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 & 19 Suitable arrangements are in place to ensure the occupants receive personal support in the way they prefer and their physical health care needs are identified, planned for and met. EVIDENCE: All three of the occupants care plans inspected at random contained very detailed manual handling assessments, which set out clearly the personal support, they each required. As previously mentioned, all the occupants met said the staff always took into account their wishes and preferences, which extended to the way staff provided their personal care. The projects accident book revealed that none of the occupants had been involved in any major or minor accidents since September 2005. Speakers Court DS0000025838.V274215.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The homes arrangements for dealing with complaints and allegations and/or suspicion of abuse are sufficiently robust to ensure the occupants views and concerns are always taken seriously and acted upon. EVIDENCE: According to the projects formal complaints log no concerns have been made about its operation since September. The two members of staff met during this inspection were both very clear when information given to them in confidence should and should not be shared with others. The projects most recent recruit went onto to say that if they were in doubt about when confidences should be shared with others they would discuss it with the projects manager. No allegations of abuse have been made within the project in the past year. The shift leader was very clear about how to respond to any allegations or suspected abuse and which agencies should be notified without delay. The shift leader was unsure whether or not more specific guidance had been established to enable staff to prevent and deal more effectively with behaviours that may challenge the service. In the absence of the registered manager it was decided not to assess the requirement pertaining this matter on this occasion. Consequently, the outstanding requirement issued in the projects previous inspection report has merely been repeated in this one and the timescale for action to address it extended. The requirement is not considered unmet. Speakers Court DS0000025838.V274215.R01.S.doc Version 5.1 Page 16 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, 26, 27, 29 & 30 The layout of the self-contained flats, which are all suitably adapted to meet the occupant’s physical needs, ensures people residing there live in an extremely comfortable and safe environment. The arrangements the project has with external agencies for maintaining essential moving and handling equipment in good working order needs to be reviewed to ensure occupants can continue to make informed choices about their life’s and maximise their independent living. Speakers Court DS0000025838.V274215.R01.S.doc Version 5.1 Page 17 EVIDENCE: There has been no significant changes made to the projects environment since it was last inspected in September 2005, although all the occupants and staff met said they believed a time specific plan had been agreed with the Housing Association responsible for the building, to begin refurbishment work in April 2006. The married couple who shared a flat said they had no doubt that they would be asked what colour they wanted their flat to be painted and agreed that the units in their kitchen had seen better days. Progress on this matter will be assessed at the projects next inspection. Having been invited to view a flat occupied by the aforementioned married couple it was evident that it had been specially adapted to meet their specific physical needs. For example, the work surfaces and light switches had all been lowered to enable the occupants to reach them from a seated position. The occupants said they had recently purchased a new washing machine. Having tested the temperature of hot water emanating from the taps attached to baths in Flats No#10 & 11 they were both found to be a safe 40 degrees Celsius at around 11.30 am. The shift leader said that as required in the projects previous inspection report all the projects water outlets had been checked by a suitably qualified engineer and more suitable preset, tamper proof and fail-safe thermostatic mixer valves fitted to ensure hot water temperatures remained constant. The shift leader also said that is was custom and practice for staff to test the temperature of bath water before the occupants get in. Furthermore, three of the Flats have also been fitted with new showers since September 2005. However, these positive comments notwithstanding, is was concerning to discover that although one occupant had initially been satisfied with the temperature of hot water provided by their new thermostatic valve, they had been unable to have a bath for the past three weeks because of a faulty hoist. The occupant said that as an interim measure staff had been giving them bed baths as they chose not to have showers. Having spoke to the projects manager over the telephone she said despite numerous calls to agency responsible for maintaining the projects hoists, no action had been taken to repair it. This matter needs to be resolved as a matter of urgency. Speakers Court DS0000025838.V274215.R01.S.doc Version 5.1 Page 18 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): 33, 34, 35 & 36 The project ensures that sufficient numbers of suitably experienced, qualified and competent staff are on duty at all times to meet the health and welfare needs of the occupants. However, to ensure the occupants benefit from being support by a well-supervised staff team the seniors who supervise their colleagues, along with the manager, must be suitable trained to perform this task. EVIDENCE: It was positively noted that the new manager has made some significant changes to the way the duty roster is organised to make it more responsive to occupant’s wishes and needs. January’s duty rosters revealed that as the occupants requested an additional third member of staff is often employed to work across part of an early shift to cover ‘peak periods of activity. This happens about three times a week and the manager and the projects only part-time member of staff are largely responsible for covering these so called ‘peak’ times. All the occupants and staff met during this inspection said they were extremely expressed with the new managers flexible approach to planning the duty rosters, which is evidently far more occupant centred. On arrival the shift leader, the projects most recently recruited member of staff, and a part-time worker, were all on duty. Speakers Court DS0000025838.V274215.R01.S.doc Version 5.1 Page 19 The project continues to experience relatively low rates of staff turnover and consequently only one new member of staff has been employed in the past six months. The new member of staff who was on shift at the time of this inspection was informally interviewed. The staff member said she had been working at the Speakers Court for the past six months as an agency member and therefore she was very familiar with the occupant’s unique needs, preferences, and daily routines. The member of staff went onto to say that Scope had insisted that she provide them with proof of her identify, two written references and satisfactory Protection Of Vulnerable Adults (POVA) and Criminal Records (CRB) checks, before being allowed to commence her permanent job at Speakers Court. This new member of staff also said that despite having worked at the project before she had still be given a vigorous interview by the projects manager and given a thorough induction, which was still on going. As required in the projects last inspection report the shift leader said a date had been arranged for her to attend a recognising, preventing and reporting abuse training, and the other staff on duty said they had attended a suitable course in December 2005. Staff training will be examined in greater depth at the projects next inspection. The shift leader said that as one of the senior members of staff who had undertaken staff supervision in the past she had not received any formal training in this area of practice, as recommended in the projects last inspection report. All staff who are responsible for supervising their colleagues must receive the appropriate training and therefore this former recommendation is made a requirement. All staff met said the projects manager continues to ensure they each receive at least one formal supervision session every two months. Speakers Court DS0000025838.V274215.R01.S.doc Version 5.1 Page 20 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): 39 & 42 The projects health and safety arrangements are in the main sufficiently robust to ensure the occupants and staff are protected from avoidable harm, although the fire risk assessment of the building needs reviewing. The project needs to be more open and transparent and publish occupants and other major stakeholders views about the service. Without an effective quality assurance system in place the service providers will not be able to measure how successful or not they have been in achieving the projects stated aims and objectives. EVIDENCE: The shift leader and all the occupants met said they were not aware that Scope had a quality assurance system in place and were all adamant that they had not been asked to complete any satisfaction questionnaires. To enable the service providers to monitor quality the process of ascertaining occupants and major stakeholders views must be continuous and the results of any surveys carry out published.
Speakers Court DS0000025838.V274215.R01.S.doc Version 5.1 Page 21 Up to date Certificates of worthiness were in place as evidence that ‘suitably’ qualified professionals had carried out periodic checks in respect of the projects gas installations and fire extinguishers. The project has a comprehensive fire risk assessment of the building in place, although it was last updated in January 2004 and will therefore need reviewing. Speakers Court DS0000025838.V274215.R01.S.doc Version 5.1 Page 22 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 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 2 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 3 28 X 29 2 30 3 STAFFING Standard No Score 31 X 32 X 33 4 34 3 35 3 36 2 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 3 12 X 13 X 14 3 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X X X X 2 X X 2 X Speakers Court DS0000025838.V274215.R01.S.doc Version 5.1 Page 23 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 YA1 Regulation 6(a) (b) Requirement Timescale for action 01/04/06 2. YA23 13.4&17.1a, Sch.3.3q 3. YA29 13(5) & 23(2)(c) 4. YA36 18(2) The projects Statement of purpose must be keep under review and, where necessary, up dated to reflect changes in provision. The occupants and the Commission must be notified of any such revision within 28 days. Occupants care plans must 01/04/06 contain more specific guidance to help staff prevent and deal more effectively with behaviours that challenge the service. All equipment provided at 10/02/06 the project for use by the occupants for moving and transferring must be maintained in good working order. Sufficient numbers of the 01/05/06 projects senior staff team must be suitably trained to formally supervise their colleagues. Documentary evidence of this training must be made available for inspection on request.
DS0000025838.V274215.R01.S.doc Version 5.1 Page 24 Speakers Court 5. YA39 12.3 & 24.1,2 & 3 6. YA42 13(4) & 23(4) An effective quality assurance system must be introduced and the results of any occupant/stakeholder holder surveys undertaken published. The fire risk assessment for the building must be subject to programmed reviews and up dated accordingly. 01/04/06 01/04/06 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 Good Practice Recommendations The manager should give serious consideration to improving the projects existing care plan format and making it far more occupant centred. Speakers Court DS0000025838.V274215.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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