Inspection on 15/11/07 for Suffolk Court

This inspection was carried out on 15th November 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Suffolk Court 10/11/08

Suffolk Court 24/01/07

Suffolk Court 30/11/05

Suffolk Court 31/05/05

Suffolk Court 17/11/04

Suffolk Court 22/06/04

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Hawkhills

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Beeches The - North Yorkshire County Council

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Carentan House

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

CARE HOMES FOR OLDER PEOPLE Suffolk Court Silver Lane Yeadon Leeds LS19 7JN Lead Inspector Catherine Paling Key Unannounced Inspection 15th November 2007 09:45 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 Suffolk Court DS0000033240.V354931.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. Suffolk Court DS0000033240.V354931.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Suffolk Court Address Silver Lane Yeadon Leeds LS19 7JN 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) 0113 2509540 P/F 0113 2509540 Leeds City Council Department of Social Services Miss Fiona Tracy Wood Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40), Physical disability (1) of places Suffolk Court DS0000033240.V354931.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th January 2007 Brief Description of the Service: Suffolk Court is a local authority home providing personal care primarily for older people of both sexes. There are 33 permanent places and seven places dedicated to respite services. The home is a two storey building on two floors with stairs and a passenger lift providing access to the first floor. Accommodation is in single rooms, all of which have en-suite facilities and there are well-equipped and large assisted communal bathing facilities. There are plenty of toilets situated throughout the building. Lounge and dining facilities are situated on both floors with the main large dining and lounge area on the ground floor. There is level access to the enclosed gardens with some rooms overlooking this attractive area. The home is situated in Yeadon and is close to many local amenities. Information about the service is available in a Statement of Purpose and Service User Guide. Copies of the inspection reports are available on request. The fees range from £70.85 to £458.86 per week. There are additional charges for hairdressing and newspapers. This information was provided by the service in November 2007. Suffolk Court DS0000033240.V354931.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit by one inspector who was at the home from 09.45 until 16.30 on the 15th November 2007. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the people who live there and in accordance with requirements. Before the inspection accumulated evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. This information was used to plan the inspection visit. A number of documents were looked at during the visit and all areas of the home used by the people who lived there were visited. A good proportion of time was spent talking with the people at the home as well as with the officers in charge and the care staff. The manager was not on duty on the day of the visit. An Annual Quality Assurance Assessment (AQAA) had been completed by the home before the visit to provide additional information. This is a selfassessment of the service provided. Survey forms were sent out to the home before the inspection providing the opportunity for people at the home; visitors and healthcare professionals who visit the home to comment, if they wish. Information provided in this way may be shared with the provider but the source will not be identified. A small number of surveys were returned and comments are included in the body of the report. What the service does well: Information is gathered about people before they are admitted to the home. People are encouraged to spend time at the home as part of the pre-admission process and to help them make up their mind about moving into the home. There is a warm and welcoming atmosphere and people said that they were very happy living at the home. Visitors are made very welcome throughout the day. Healthcare needs are closely monitored and medical staff are involved in a ‘timely manner’ as are other healthcare professionals. Staff have a pleasant and patient approach to the people they are caring for and encourage independence, proving support when it is needed. Suffolk Court DS0000033240.V354931.R01.S.doc Version 5.2 Page 6 Everyone spoken with said that they knew who to talk to if they were unhappy or had concerns. There are good assisted facilities for respite care. 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. Suffolk Court DS0000033240.V354931.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 Suffolk Court DS0000033240.V354931.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): 3 (Standard 6 does not apply to this service) People who use the service experience good quality outcomes in this area. Pre-admission information is gathered together before people move into the home and are staff are knowledgeable about people’s needs. We have made this judgment using available evidence including a visit to this service. EVIDENCE: Information provided in the AQAA states that all people considering moving into the home are expected to spend some time there, even an overnight stay, as part of the assessment period so that they and the home can be sure that needs can be met. People and their relatives are welcome to visit at any time without an appointment as part of the process. Local authority assessment information is also seen in the individual records. It was stated in the AQAA that those people admitted for regular respite care Suffolk Court DS0000033240.V354931.R01.S.doc Version 5.2 Page 9 have their needs reviewed at every admission. This was not clear in the sample of respite records looked at and records were undated and unsigned. The relatives of someone who was moving into the home the following day were visiting the home to bring personal belongings and other items to personalise the room. They were made welcome by staff. The relative of someone admitted earlier this year said that staff had worked hard to help her settle at the home. This person had mental health needs and could not remember moving into the home but seemed quite settled. Suffolk Court DS0000033240.V354931.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 and 10 People who use the service experience adequate quality outcomes in this area. Health care needs are met but the lack of detailed care plans provides the opportunity for some care needs to be overlooked. The staff respect the privacy and dignity of people living at the home. Some medication practices put people at potential risk. We have made this judgment using available evidence including a visit to this service. EVIDENCE: All the people living at the home permanently have a lifestyle plan providing information about care needs. The level of detail was variable with some good detail seen about care preferences. There was clear evidence that health care needs are identified and met with the input of other healthcare professionals. Suffolk Court DS0000033240.V354931.R01.S.doc Version 5.2 Page 11 Information provided in the AQAA stated that ‘primary health care needs are met and service users have access to specialist services’ and ‘records demonstrate responsiveness to health needs and monitoring of needs’. Records demonstrated that staff do monitor health care needs and one general practitioner (GP) commented via a survey that the staff ‘seem to react in a timely manner’ when involving medical staff. In the case of one person who had been identified as being at nutritional risk it was recorded that nutritional supplements were needed and that meals were served on small plates so as to not ‘overface’ her. Where mobility issues are identified the input of the occupational therapist is arranged. People living at the home also have access to physiotherapist services. Healthcare professionals visiting the home felt that staff respect the dignity of people living there and observation on the day of the visit supported this view. Responses in surveys stated that the service; • ‘takes personal interest in individuals’ • ‘treats clients with respect’ • and that ‘staff are flexible and willing’. Some of the information in the Lifestyle plans needed to be updated to make sure all the staff had access to important information. For example, one person living at the home had recently been bereaved and records had not all been updated to reflect this and there was little information for staff on what support and help this person might need. Another person’s plan stated that staff were ‘all aware of what help is needed’. This does not provide evidence of care given and would not be enough for agency staff to know how to support this person. The AQAA also states that the designated key worker ‘works with the service users on the development and reviewing of care plans’. This was not clearly evidenced in the sample looked at and where information appeared to have been updated it was not always dated or signed. This makes it hard to be certain that staff have access to the most up to date information. Those people admitted for respite care have their care needs documented on a different type of care plan that provides an overview of their care needs. The respite care plan looked at was undated and unsigned and although this person came to the home for regular respite there was no clear evidence of a review of care needs at each stay at the home. Local authority documents were available in the records and had been reviewed in March 2007. All those involved in the administration of medication have had training that is provided by the local pharmacy. The medication administration system was changed earlier this year and staff had had training on the new system. The lunchtime medication round was observed and it was of concern that the blister packs were taken from the lockable drug trolley and left on an open Suffolk Court DS0000033240.V354931.R01.S.doc Version 5.2 Page 12 trolley during the medication round. At times they were left unattended altogether while the person administering the medications went out of the room. This person was also observed handling tablets and placing one on the tablecloth for someone to take after their lunch. She did not observe this person taking the tablet. This is poor practice. It was clear from observation that staff treat people with respect and preserve their dignity. Discussions with staff and people living at the home made it evident that staff know them well and know how to meet care needs. Suffolk Court DS0000033240.V354931.R01.S.doc Version 5.2 Page 13 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 and 15 People who use the service experience good quality outcomes in this area. The social, religious and cultural needs of people living at the home are met. People are able to maintain contact with family and friends and they are encouraged to be part of the decision making at the home. A good, varied and nutritious diet that takes into account individual choice is served at the home. We have made this judgment using available evidence including a visit to this service. EVIDENCE: It was stated in the AQAA that ‘Choice is at the forefront of all actions within the home’ and that ‘external and internal events are supported in the home’. Observation and discussion with some of the people living at the home made it clear that people were able to exercise choice and control over their daily lives as far as possible. Returned surveys and comments received at the visit provided evidence that people are happy at the home. The home is situated close to a range of shops and facilities and those who are able come and go as they wish. Others go out regularly with friends and relatives. Suffolk Court DS0000033240.V354931.R01.S.doc Version 5.2 Page 14 Visitors were warmly welcomed into the home by the staff, and said that this was always the case. Some of the people living at the home have been involved in an arts project run by Skippko Arts Team. This project is over a 12 week period for two hours each week. It involves a small number of people at the home working with the two project workers to produce memory books. On the day of the visit the project workers were at the home and five people were actively engaged in cutting out and colouring items for the memory books. This was clearly an enjoyable activity. One person told of how she was able to spend the day how she wanted and that questionnaires were distributed regularly by the home as part of their monitoring of the service. Care staff were observed to assist and support people in such a way as to encourage their independence. They had a pleasant and patient approach to people. The lunchtime meal was observed and conducted in an organised way. People were given a drink of squash with their meal and were offered a hot drink afterwards. There was a choice of main course and people were offered second helpings. One person who did not want either hot choice was given several alternatives and eventually settled for a milky drink. Staff clearly knew individual likes and dislikes. The meal was a sociable time with staff, once everyone had been served, also sitting down for a meal with the residents. Suffolk Court DS0000033240.V354931.R01.S.doc Version 5.2 Page 15 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 and 18 People who use the service experience good quality outcomes in this area. A robust adult protection and complaints policy and procedure ensures that people who live at the home are listened to and are protected from abuse. We have made this judgment using available evidence including a visit to this service. EVIDENCE: It was stated in the AQAA that there is a ‘complaints and compliments systems, which responds comprehensively to issues raised’ and that ‘We resolve and acknowledge mistakes and identify ways of improving’. There are clear records kept of complaints and compliments received. The complaints book indicated that one complaint had been received at the home and records gave clear evidence that it had been responded to appropriately and remedial action taken with the organisation of additional training for staff. There is a complaints procedure that is displayed in the home and people were clear that they knew who to talk to if they had a concern. Suffolk Court DS0000033240.V354931.R01.S.doc Version 5.2 Page 16 The AQAA stated that ‘all the team are trained in adult protection issues’. This training is ongoing for staff and there is also to be training with regard to the Mental Capacity Act 2005. Suffolk Court DS0000033240.V354931.R01.S.doc Version 5.2 Page 17 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 and 26 People who use the service experience good quality outcomes in this area. People live in a well maintained and safe environment. Good levels of specialist equipment ensure that peoples’ independence is maintained. We have made this judgment using available evidence including a visit to this service. EVIDENCE: It was stated in the AQAA that ‘the environment is maintained to a high standard’ and this was found to be the case with corridor carpets being fitted to the first floor in the day of the visit. The AQAA also stated that over the last 12 months the ongoing decoration programme has included 10 bedrooms, the dining area and corridors as well as Suffolk Court DS0000033240.V354931.R01.S.doc Version 5.2 Page 18 the recent purchase of a ‘rise and fall bath’ in a ground floor bathroom. There are plans for the coming year for the addition of a conservatory. Two rooms have been fitted to a high standard for respite use for a couple with an adjoining lockable door. Another room is adapted for respite for people with a physical disability. Only personal laundry is done on site and there are dedicated laundry staff five days a week. Suffolk Court DS0000033240.V354931.R01.S.doc Version 5.2 Page 19 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 and 30 People who use the service experience poor quality outcomes in this area. The numbers and skill mix of staff were not sufficient to guarantee that peoples’ needs would be consistently met. The staff are trained and competent to do their jobs. People are protected by robust recruitment procedures. We have made this judgment using available evidence including a visit to this service. EVIDENCE: Observation on the day of the visit clearly indicated that staff were working under pressure throughout the whole day. This was made worse between 14.00 and 15.00 when there were only two carers and the care officer on shift for the 30 people currently at the home. There were no kitchen staff from 14.00 until 16.00 meaning that the care staff had to prepare the afternoon drinks, in addition there were no laundry staff. This is a busy home and the people living at the home are becoming increasingly dependant. Staff said that these staffing levels were not an unusual occurrence and they were unhappy and constantly being asked to cover shortfalls in staffing, for example, in the kitchen. They said that people living at the home wanted a cooked breakfast but due to the staffing shortfalls this was not possible. They Suffolk Court DS0000033240.V354931.R01.S.doc Version 5.2 Page 20 gave the example that care staff come on shift at 07.30 and kitchen staff come on at 08.00. This has meant that the Care Officer does breakfast as well as administer the morning medications. There is no administrative support for the Care officers and this means that they are taken away from care duties. This has also meant that the home uses an answer machine when busy which can make it very hard to get through to the home by telephone. It is of further concern that there are just two staff overnight in a large building for up to 40 people. Concerns about staffing were raised at the previous inspection in January 2007 but it appears that no action has been taken. Shortages have been exacerbated over the previous 12 months due to high sickness levels. The AQAA stated that ‘We routinely exceed minimum training requirements’ and that there is a ‘vigorous supervision and appraisal scheme’. The formal supervision of care staff is well established and is used in conjunction with appraisal to identify training needs. Records of training are on individual files. An alternative method of providing this information needs to be considered for inspection purposes. Care staff are working towards National Vocational Qualifications in care and almost 50 of them have achieved the award at level 2. The AQAA states that ‘recruitment is robust and secure’. Suffolk Court DS0000033240.V354931.R01.S.doc Version 5.2 Page 21 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 and 38 People who use the service experience adequate quality outcomes in this area. The home is reasonably well managed. The interests of the people who live there are seen as important to the manager but some practices put people living at the home at potential risk. We have made this judgment using available evidence including a visit to this service. EVIDENCE: The registered manager is experienced in care. She has completed training in health and safety but has yet to complete an NVQ in care at level 4 and a management and leadership development qualification. Suffolk Court DS0000033240.V354931.R01.S.doc Version 5.2 Page 22 It is stated in the AQAA that she has a ‘positive and enthusiastic attitude, which reflects in the care given by staff’. There are systems in place for the ongoing formal monitoring of the service with quality assurance questionnaires being distributed on a regular basis. However, the information is not collated and made available to all interested parties. This should be done in the interests of continuing to improve the service to the people living at the home There is a whole range of risk assessments in place for safe work practices and for the building. Records are kept of any accidents occurring at the home and a monthly summary is produced. Records of accidents were looked at. The current method of simply keeping copies does not provide evidence of any analysis that to identify any trends or issues that could be addressed to reduce the number of accidents at the home. The standard of recording was variable with some reports not including the time of the accident at all or not being clear whether it was morning or afternoon. It was also identified that several accidents that should have been reported to us under Regulation 37 had not been. For example, accidents that had resulted in injury requiring a hospital visit or admission. The provider carries out monthly visits to monitor the conduct of the home, as required. Reports are produced and are available at the home. Staff meetings are held when they are needed but there is a formal handover between shifts to aid communications. Residents meetings are held with one planned for the day after the visit. The previous meeting had been held in May and notes of this meeting were available. Topics discussed included food, complaints and compliments, in-house activities and the wish of some people to have trips out from the home. Suffolk Court DS0000033240.V354931.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 1 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Suffolk Court DS0000033240.V354931.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 15 Requirement Information about people’s care needs must be accessible to care staff to make sure that people are looked after properly. Otherwise care needs could be overlooked There must be evidence that people and/or their representatives are involved in the development of care plans. The registered manager must make sure that all staff are aware of the medication policies and procedures and follow them. Particular attention must be paid to the safe storage of medication. This is so that people are not put at potential risk by unsafe practice relating to the administration of medication. The staffing arrangements must be reviewed to make sure that there are enough staff and the right skill mix to meet the needs of the people living at the home. DS0000033240.V354931.R01.S.doc Timescale for action 07/04/08 2 OP9 13(2) 04/02/08 3 OP27 18(1)(a) 04/02/08 Suffolk Court Version 5.2 Page 25 4 OP31 9(2)(b)(i) 5 OP38 37 The registered manager must achieve the appropriate qualifications to make sure that she has the knowledge and skills to manage the home effectively for the benefit of the people living there. Accidents to people living at the home and incidents affecting the smooth running of the home must be notified as required. 05/05/08 04/02/08 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 Refer to Standard OP3 OP28 Good Practice Recommendations People admitted to the home for regular respite should have their care needs re-assessed. This should be clearly documented so that care needs are not overlooked. The provider and the manager should continue to encourage staff to undertake NVQ in care to make sure that all the staff are trained and competent to meet the needs of the people at the home. The target of 50 should be aimed for. The outcome of audits carried out as part of the quality assurance programme should be shared with all interested parties. Action plans produced to address shortfalls should also be made available. The availability of information about staff training should be reviewed to make sure that it is accessible for inspection. 3 OP33 4 OP30 Suffolk Court DS0000033240.V354931.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection 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 Suffolk Court DS0000033240.V354931.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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