Inspection on 06/09/07 for St Brendans

This inspection was carried out on 6th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

St Brendans 23/10/08

St Brendans 05/02/07

St Brendans 20/02/06

St Brendans 09/08/05

St Brendans 20/09/04

St Brendans 17/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE St Brendans 175 Ashburnham Road Luton LU1 1JW Lead Inspector Sally Snelson Unannounced Inspection 6th September 2007 10:15 X10015.doc Version 1.40 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 St Brendans DS0000014959.V346389.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 Older People. 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. St Brendans DS0000014959.V346389.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Brendans Address 175 Ashburnham Road Luton LU1 1JW 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) 01582 728737 01582 726022 jetha@hotmail.com Mr Jethra Kara Mrs Bhavna Kara Vacant Care Home 26 Category(ies) of Dementia - over 65 years of age (26), Old age, registration, with number not falling within any other category (26) of places St Brendans DS0000014959.V346389.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th February 2007 Brief Description of the Service: St Brendans is a three storey period house in a residential area of Luton. It is on a bus route and within a short drive of nearby shops, post office, public houses and places of worship. Accommodation is provided on all three floors of the home, with 20 single bedrooms and 3 double bedrooms. Access to the upper floors is via stairs or a lift. There is a small lounge on the fist floor and two further lounges and dining room on the ground floor. The kitchen and laundry facilities are located on the ground floor. There is an attractive garden with an enclosed patio area at the rear of the home with raised flowerbeds and garden furniture. The fees for this home vary from £418.00 per week, to £459.00 per week, depending on the funding source. Inspection reports are stored in the entrance hall and available to residents and their families. St Brendans DS0000014959.V346389.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out in accordance with the Commission for Social Care Inspection’s (CSCI) policy and methodologies, which require review of the key standards for the provision of a care home for older people that takes account of residents’ views and information received about the service since the last inspection. Information from the home, through written evidence in the form of an Annual Quality Assurance Assessment (AQAA) has also been used to assess the outcomes within each standard. Evidence used and judgements made within the main body of the report include information from this visit. The inspection of St Brendan’s was a key inspection, was unannounced and took place from 10.15am on 6th September 2007. One of the proprietors, Mrs Bhavna Kara, was present throughout. At the time of the inspection the manager’s position was vacant. Feedback was given throughout the inspection. During the inspection the care of three people who used the service was case tracked. This involved reading their records and comparing what was documented to what was provided. In addition to sampling files, people who lived at the home, staff and visitors were spoken to and their opinions sought. Any comments received from staff or residents about their views of the home plus all the information gathered on the day was used to form a judgement about the service. The inspector would like to thank all those involved in the inspection for their input and support. What the service does well: The home offers the people who live there with a secure friendly place in which to live. The staff team are happy at the home and enjoy working and interacting with the people who live. The home is very friendly and welcomes visitors at any time. St Brendans DS0000014959.V346389.R01.S.doc Version 5.2 Page 6 The home has a good complaints procedure that residents could understand, and it was apparent that staff were committed to keeping residents safe from harm. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Brendans DS0000014959.V346389.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Brendans DS0000014959.V346389.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5,6, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Assessments undertaken before a resident is admitted to the home ensured that their care needs could be met.. EVIDENCE: The home had a statement of purpose and a service users guide, which was displayed in the entrance hall. The proprietor was aware of the need to update these documents to reflect that the manager’s post was vacant. As at previous inspections assessment documentation were viewed in residents files. The standard of information was sufficient and gave information on the St Brendans DS0000014959.V346389.R01.S.doc Version 5.2 Page 9 physical, social, emotional and psychological needs of the resident’s. In addition assessments undertaken by the funding agencies were also seen in some of the care files examined. At the last inspection it was noted that three residents with a mental health diagnosis were accommodated in the home and the registration did not cover this category. The proprietor stated that she had applied in February 2007 to vary the registration but when she contacted us in May 2007 it became apparent that the registration application had not been received. Since then a second application had been made but returned due to the wrong fee being included with the application. One of the identified residents was not at the home and the two others were not receiving any specific treatment or support for their mental health condition. The manager was advised to read the guidelines for the mental health category, decide if any residents fell into this group as a primary need and if the staff team had the skills and qualifications to meet their needs, and if necessary apply to vary the registration immediately. Failure to do so would result in enforcement action being considered, as the home would be admitting outside of the category of registration. The inspector forwarded the proprietor the links to the relevant guidance to assist her decision. Intermediate care is not offered at this home. St Brendans DS0000014959.V346389.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans had not been written in sufficient detail to ensure that the staff team could consistently meet the care needs of the residents. However it was clear that staff verbally communicated changes of care needs to each other, and at the time of the inspection residents care was not compromised. EVIDENCE: Care plans were in place and the staff were aware of them, but did not appear to be using them as a working document. The staff team reported that they knew the residents well and would relay any care changes to each other and therefore not always update documentation. St Brendans DS0000014959.V346389.R01.S.doc Version 5.2 Page 11 At the last inspection the need for care plans to be written in greater detail had been identified. Work had started on this process, but because the manager had had a period of absence and had then resigned it had not been completed. At the time of the inspection the proprietor was working on the care plans and showed the inspector a sample of those that had been completed. They had been written to cover more activities of daily living, but still needed to be in greater detail. There was also a need for all those people with a diagnosis of dementia to have this reflected throughout their care plans so that staff could provide appropriate individual care and support for them in all areas of their care. For example appropriate support at mealtimes, when making choices. The AQAA completed by the proprietor prior to the inspection suggested that residents and/or families were involved in care planning. In the documents sampled this was not apparent although a relative had completed an agreement to the use of bed-rails. Residents spoken with confirmed that they received visits from a General Practitioner or Community Nurse as and when they needed. Records of these visits were seen. In addition letters from Luton and Dunstable Hospital were also seen demonstrating residents attendance at specialist clinics when required. Staff were aware of how to contact medical professionals if a resident became unwell. One of the residents who care was tracked had appropriate pressure relieving equipment on loan to prevent the development of pressure areas. Other residents were seen to being using pressure-relieving equipment. However it is important that the documentation supports the care provided. For example; the resident that had the pressure relieving equipment had risk assessments that suggested the need for this equipment but there was nothing to suggest it had been ordered or that the risk assessments had been kept under review. It was sometimes difficult to be sure when assessments had taken place as documents were not always signed and dated. Throughout the inspection residents were supported to move around the home, for example to the bathroom or the dining room. Staff used a variety of moving and handling equipment in the correct way. Again the care plan did not always identify the equipment to be used. Medication records were thorough and always signed by the member of staff administering the medication. An audit of the medicines indicted the correct medicines had been given. During the inspection residents were witnessed being treated with respect by all the staff, including the ancillary staff. Post was given to residents unopened and they were supported with it if necessary. However because of space it was noted that a repair to a trolley was being carried out in a residents bedroom without their knowledge. St Brendans DS0000014959.V346389.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A well balanced diet and choices were available at mealtimes ensuring that residents nutritional needs were met. EVIDENCE: It was apparent that that people who lived at St Brendan’s had some flexibility of lifestyle. For example, they could get up and go to bed when they wished, but baths were offered on designated days. Information provided by the home showed that a range of activities were available, examples include entertainment, outings, games, reminiscence and bingo. The home had recently advertised and successfully recruited a part time activities co coordinator who had previous experience of working with people with dementia. In order to meet this standard residents care plans should St Brendans DS0000014959.V346389.R01.S.doc Version 5.2 Page 13 include more information about their previous interests and pastimes and the activities they would like to take part in. Following an activity information should be recorded about the residents reaction. Visitors to the home included visiting religious representatives that would carry out religious services, a mobile shop and library, in addition to a hairdresser and aromatherpist. The residents who choose to use them funded the later two. During the inspection it was noted that relatives and friends of the residents were welcomed into the home and could visit at any time. Menus were written on a board within the main dining area of the home. Observations of lunch showed residents had been given a choice, close to lunchtime, of liver and bacon or omelette. The cook went to all the residents to ask then what they would like and took with her a written description of the meal but nothing in pictorial form, which might have been easier for those residents with dementia to understand. staff were seen to assist those who required help to eat their meals. All residents spoke highly of the food available at the home. We were encouraged to see that residents were given their meal on different size plates, according to their appetite. Residents were offered regular drinks during the day. There were biscuits to go with the drinks but these were given to the residents and although they were asked if they would like more they did not choose their biscuit or take it out of a tin or off a plate. St Brendans DS0000014959.V346389.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Robust procedures for making complaints and safeguarding people ensured that those people living and working at St Brendan’s were kept safe. EVIDENCE: As noted at previous inspections the home had a complaints policy that included a reasonable timescale in which the complainant could expect a response. Although the home had not had complaints made to or about it since the last inspection the proprietor and the staff were able to discuss their role if a complaint was made to them. The proprietor commented that ‘ the complaints procedure is used in a constructive manner to improve our service’. The home had in place a policy on abuse and a copy of the most recent guidance for the Protection of Vulnerable Adults that contained the correct reporting of any alleged abuse. Training records showed staff had received training in this area. St Brendans DS0000014959.V346389.R01.S.doc Version 5.2 Page 15 There had been two safeguarding referrals made since the last inspection and we had been included in any reporting and meetings where it was apparent that appropriate actions had been taken. St Brendans DS0000014959.V346389.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,24,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was clean and tidy but there were areas that were in need of redecoration in order to ensure that the people who lived there lived in a homely and comfortable environment. EVIDENCE: The accommodation was provided across three floors, a shaft lift was in place to access all these areas. There were communal areas on both the ground and first floors and a variety of assisted bathrooms. Residents had access to the garden, which were well kept. On the day of the inspection residents were St Brendans DS0000014959.V346389.R01.S.doc Version 5.2 Page 17 keen to be in the garden, where there was a good selection of garden furniture for their use. Other residents who did not want to be outside enjoyed the view of the garden. Residents were encouraged and supported to personalise their bedrooms with processions and small items of furniture from home. There were no unpleasant odours noted in the home. Following the last inspection the management had been required to redecorate parts of the ground floor and refurbish as necessary by June 2007. Since then the home had been awarded a grant from the council and had had plans made to knock some of the communal space into one. They had therefore delayed replacing soiled carpets. The carpet had been cleaned and as long as the work starts imminently this was acceptable, but the requirement would be remade. St Brendans DS0000014959.V346389.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The homes commitment to training ensured that the staff providing the care had the most up-to-date knowledge available. EVIDENCE: The home employs 18 care staff and three ancillary staff. At the time of the inspection 16 of those staff had NVQ level 2 or above. This home should be commended on its commitment to training. There was also evidence in files that all staff, regardless of their past experience completed an induction programme. Staff rotas indicated that four staff were on duty at all times during the day and two at night. The management must keep this under review and reconsider when the home is full. Training records showed that courses attended by staff in the past 12 months included, dementia awareness, fire safety, moving and handling. Staff spoken St Brendans DS0000014959.V346389.R01.S.doc Version 5.2 Page 19 to were able to discuss the training they had received and how they related it to their work. The home would benefit from having a training matrix in addition to individual training files so that it was easy to see who had done what training when and what needed to be updated. Examination of staff files was undertaken to look at recruitment practices in the home as at the last inspection it was found that that the most recent member of staff to be appointed had started work prior to minimum checks being in place. At this inspection it was clear that a new starter had not commenced work until the checks had been satisfactorily returned. However some older files did not have evidence of Criminal Record Bureau checks. The owner reported that in line with guidance she had destroyed those Criminal Record Bureau records that had been seen at the last inspection. However the guidance goes on to state, a record of the date of issue of a Disclosure, the name of the subject, the type of Disclosure requested, the position for which the Disclosure was requested, the unique reference number of the Disclosure and the details of the recruitment decision taken, must be held. Therefore the management must ensure that all this information is on each file in the timescale given. St Brendans DS0000014959.V346389.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,37,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. In order to move forward and meet the requirements made at this and the last inspection, a manager with appropriate experience must be appointed as soon as possible. EVIDENCE: The Registered Manager had left the home one month prior to this inspection. The vacancy had been advertised but at the time of the inspection a St Brendans DS0000014959.V346389.R01.S.doc Version 5.2 Page 21 replacement had not been identified. One of the owners of the home, Mrs Kara, had been spending time at the home since then. It was acknowledged that in that time she had recognised the need for improvements in many areas, and had started to make changes for example the care plans. Since becoming proprietor of the home Mrs Kara has completed an NVQ level 4 and has started her Registered managers Award, however she does not have plans to manage the home permanently. Records of money held by the home on behalf of residents were viewed. The receipts and other information seen were of a good standard and provided a clear audit trail. All balances checked were noted to be correct and receipts of any expenditure retained. There was evidence that finances had been audited monthly by the manager. In 2006 Mrs Kara had included a wide range of stakeholders, including residents and their families, GP’s community nurses students and a aromatherapist in a satisfaction survey. It was clear that changes had been made to the home and the care provided as a result of this survey and those involved had been written to about the outcome. In order to fully meet this standard this piece of work must be completed at least annually and the results used to influence the planning reviewing and development of the business plan. The owner admitted that staff supervision had not been maintained as regularly as the required six times a year. She stated that she had ensured that the new starter had been supervised but had not been able to have dedicated supervision time with all staff. She was aware of the importance of supervision but felt staff believed that a dedicated time was not always necessary as the past manager and herself had always made themselves available to staff. Records were correctly stored but as already discussed were not always of an acceptable standard, and some were not dated and signed. For example, it was noted that paramedics had been called to poorly residents who were then either treated at the home or moved to hospital but we were not notified as required under Regulation 37. Health and safety records showed that the maintenance person employed at the home undertakes tests. Fire safety checks, water temperatures and fridge temperatures were some of the checks noted to be undertaken. Staff training records also showed staff had undertaken training in areas that included, moving and handling, food hygiene and fire safety. St Brendans DS0000014959.V346389.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 x 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 3 X X 3 X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 1 2 3 St Brendans DS0000014959.V346389.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO 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 OP4 Regulation Requirement Timescale for action 28/10/07 10, 11, 12 No resident must be admitted to & 13 the home whose needs fall outside of the category of registration that the home holds. There was proof that this process had been started so a short extended timescale has been given. 2. OP7 12(1)(a) & 15 Care plans must contain sufficient guidance and instructions to staff on the support and care that they should provide for each assessed need. There was proof that this process had been started so a short extended timescale has been given. 01/11/07 3 OP8 4. OP19 12,14,&15 All aspects of the service users care must be regularly assessed and appropriate assessments of risk made and any necessary changes or treatments provided. 23(2)(d) Redecoration must be undertaken in areas such as the DS0000014959.V346389.R01.S.doc 01/11/07 01/12/07 St Brendans Version 5.2 Page 24 ground floor corridor and replacement of the sitting room carpet ensure service users have a pleasant environment in which to live. This requirement has been remade as a grant has been applied for. 5. OP29 12(1)(a) & 19 The home must keep some 01/12/07 evidence that Criminal Record Bureau checks have been applied for. Where these are not available new checks must be completed. The proprietors must appoint a manager as soon as possible, in order to work on the improvements necessary. The propritors must ensure that monitoring of the home is continuous and that the information is published and used to inform the annual development plan. All staff must be formally supervised at least six times a year. All staff must be responsible for ensuring that all documentation is signed and dated and kept up to date. 01/11/07 6 OP31 8 7 OP33 24 (1) (a)(b) 01/01/08 8 9 OP36 OP37 18(2) 17 (1) & (3) (a) 01/11/07 18/10/07 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 OP1 Good Practice Recommendations Management must ensure that the Statement of Purpose and the service users guide is kept up-to-date and DS0000014959.V346389.R01.S.doc Version 5.2 Page 25 St Brendans 2 3 4 5 OP10 OP12 OP14 OP30 reviewed at least annually. Service users rooms should not be used without their permission. There should be more documentation about service users past interests and how activities are planned. Service users must be offered choices wherever possible. There should be evidence of the future training needs of the staff team. St Brendans DS0000014959.V346389.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bedfordshire & Luton Area Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 St Brendans DS0000014959.V346389.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!