Inspection on 14/03/07 for The Old Galleries

This inspection was carried out on 14th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Old Galleries 13/03/09

The Old Galleries 22/02/06

The Old Galleries 18/09/05

The Old Galleries 15/03/05

The Old Galleries 13/08/04

The Old Galleries 15/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 The Old Galleries High Street Bideford Devon EX39 3AA Lead Inspector Andy Towse Key Unannounced Inspection 14th March 2007 11:30 The Old Galleries DS0000022115.V300862.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Old Galleries DS0000022115.V300862.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Old Galleries DS0000022115.V300862.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Old Galleries Address High Street Bideford Devon EX39 3AA 01237 425601 01237 425842 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) Mrs Barbara M Haywood Mrs Barbara M Haywood Care Home 8 Category(ies) of Learning disability (8) registration, with number of places The Old Galleries DS0000022115.V300862.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. This variation allows three named persons, in the category of MD Mental Disorder to remain in the home The maximum number of placements, including that of the named persons, will remain at 8 On the termination of the placement of the named persons, the registered person will notify the Commission in writing and the particulars and conditions of this registration will revert to the category LD Learning Disability only 22nd February 2006 Date of last inspection Brief Description of the Service: The Old Galleries has provided 24-hour care for 8 adults under 65 years of age with learning disabilities. The emphasis of the home is to enable residents to lead fulfilling lives through the development of social and daily living skills. The home is a listed building, situated in the main High Street of Bideford, and has been totally refurbished. The accommodation comprises of single accommodation, five of which have ensuite facilities. To the rear of the property is an enclosed garden, with outbuildings containing a laundry room. There are no parking facilities at the home, but it is in easy walking distance of a number of street parking bays and public car parks. Fees levied vary from £320 --£1200 a week with additional fees levied for transport, chiropody and hairdressing. In some instances residents also fund from certain of their benefits 1:1 staff support for accessing the community. The Old Galleries DS0000022115.V300862.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 inspection, which took place over a period of seven hours. The information contained in this report was obtained from surveys returned by both residents and staff prior to the inspection and also from a questionnaire completed by the registered manager. This information was complemented by the inspection, which included a site visit, discussions with the management, staff and residents together with inspection of records, including care plans. What the service does well: What has improved since the last inspection? The home is currently improving its medication procedure by consulting with the general practitioner regarding the use of homely remedies. The registered manager is to introduce a new induction programme which will ensure that staff receive training relating to the needs of people with a learning disability. The Old Galleries DS0000022115.V300862.R01.S.doc Version 5.2 Page 6 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. The Old Galleries DS0000022115.V300862.R01.S.doc Version 5.2 Page 7 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 The Old Galleries DS0000022115.V300862.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admissions process ensures that residents’ needs are assessed prior to admission to the home. EVIDENCE: The case files of three residents were examined. All of these residents had previously been accommodated at Bidna House. Bidna House is owned and run by the same management as manage Old Galleries. This meant that the needs of these residents were known to the staff and management at Old Galleries prior to their being admitted to the home. One file was of a resident who had been admitted to Bidna House only a few months prior to being admitted to Old Galleries. The file of this resident contained reports from various professionals such as psychologists and occupational therapists. These reports gave the home a comprehensive background to the prospective resident. Further information was obtained by the registered manager who visited the prospective resident and carried out an The Old Galleries DS0000022115.V300862.R01.S.doc Version 5.2 Page 9 assessment of this person’s needs. This assessment covered issues such as psychotic symptoms, self-care, psychological distress, intimate relationships and educational background. The Old Galleries DS0000022115.V300862.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are assisted in achieving the lifestyle they choose by involvement in regularly reviewed care plans. Residents would benefit from contracts which clearly state if additional charges are required to maintain their independence and community involvement. EVIDENCE: All residents at Old Galleries have files which contain care plans. Some had plans written by social services staff as well as the ones compiled by the home. The home obtains information from residents about the goals which they want to achieve and the activities which they want do. The plan then goes The Old Galleries DS0000022115.V300862.R01.S.doc Version 5.2 Page 11 on to state how the resident will achieve the things they want to do. It also states the help that the resident may need in achieving these aims. And a timescale for achieving them. The care plans also include details of activities which residents would like to participate in. In one instance these activities had not been achieved, but this was due to the resident having ongoing problems. An appointment had been made with a general practitioner in order that these could be addressed. Care Plans were seen to be reviewed regularly. In the plans looked at this showed that residents undertook activities which they had chosen and which assisted them in achieving their goals. An example of this was one resident had attended a cookery course at a local college in order to develop skills which would enhance his/her independence. Files also contained risk assessments. These safeguarded residents. An example was that certain residents lacked the ability to go into the community without staff accompanying them. In these instances, objectives of community participation were achieved by staff accompanying residents to places like libraries or cafes in groups or individually. In instances where residents received individual support to participate in the community, which was identified on their care plans, they were charged additional fees for this. An example of this being a resident who likes going to the library but requires staff assistance for this. This resident said that they enjoyed going to the library and showed books which had been obtained from there. There is reference in this resident’s care plan to going to the library as part of his/her involvement with the community. The homes supports this resident in going to activities within the community as part of a group, however, it was explained by the home’s management, that should residents be taken out on a 1:1 basis, an additional charge is levied from the resident’s benefits. The Old Galleries DS0000022115.V300862.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to live as independently as they are able and access the community regularly. Residents enjoy a menu which reflects their individual preferences. EVIDENCE: Currently none of those resident at Old Galleries is in employment. However in discussion the Head of Care spoke of being in the process of approaching a The Old Galleries DS0000022115.V300862.R01.S.doc Version 5.2 Page 13 local supermarket with the intention of discussing the possible employment of a resident. The review of this resident, which had been held recently, also showed that the care manager was seeking avenues of therapeutic work for this person. Discussions with residents and staff and examination of files showed that residents had attended courses at the local college. Two of the residents assist with the administration of a social group for people who have learning disabilities. Within the home residents take responsibility for tasks, such as tidying their rooms. Residents also access facilities within the local community. These include specialist activity groups for people with learning disabilities such as the Breakaway, Gateway and Meerkat groups as well as an activity group set up between several homes for people with learning disabilities. In addition residents go out in the transport, which is shared with Bidna House, to car boot sales, to have cream teas in the community and visit venues of their choice. Depending upon their ability and as stated in their risk assessments, residents access the community. Some need staff support, either individually or in groups to go to cafes, shops or the library. Some are able to use public transport and live more independently. Within the home all residents who are assessed as being capable had keys to their own rooms and also keys to the front door of the premises. This allows those who area able to have the freedom to come and go as they please. Some residents do have links with family and relatives and this is encouraged by the home. On the day of the inspection one resident was visiting his/her mother and another had a relative visiting him/her. The menu was discussed with staff and residents. Residents confirmed that they liked the food available at Old Galleries. The menu is compiled b y a member of staff who discusses it with residents. Minutes of residents meetings showed that these served as a forum where residents could express their preferences for inclusion on the menu. In discussion one resident said what he/she liked to eat and it was found to be on the menu. Staff were aware of what food residents liked or did not like and separate food was available for those who did not like what was on the menu. An example of this was the food prepared for one resident who was vegetarian. Residents can choose where they eat and one resident often chooses to eat separately. The Old Galleries DS0000022115.V300862.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health and welfare needs are met through regular contact with healthcare professionals and appropriate policies and procedures. EVIDENCE: Care Plans gave detailed information regarding how residents were to be assisted with regard to personal care and other forms of support. This included instructions for staff to prompt with certain aspects of care in order that the resident achieved more for him/her self and therefore became more independent. Where appropriate care plans stated what level of assistance was needed, and also what frequency certain tasks should be carried out. Examples of these were residents being assisted with cleaning teeth and frequency of bathing and hair washing. The Old Galleries DS0000022115.V300862.R01.S.doc Version 5.2 Page 15 In discussion the Head of Care spoke about the privacy of residents being respected. An example given was of one resident who was specific about the gender of the staff who assisted him/her with personal care. Whilst this was respected reference to it could not be found on the care plan. Examination of the daily records of residents showed that their healthcare needs were met. There were regular visits to the home by various healthcare professionals to address the needs of individual residents. These included a fortnightly visit by a community psychiatric nurse, a six monthly visit by a specialist diabetic nurse and regular contact with a consultant psychiatrist specialising in the care of people with learning disabilities. All residents undergo an annual medical review carried out by a general practitioner. Entries on files also showed that the well being of residents was monitored and that when appropriate, healthcare support was sought in attempts to resolve any problems which were identified. The home has appropriate policies regarding the administration, storage and recording of medication. With regard to homely remedies, the home had recently contacted the general practitioner who worked closely with the home and were anticipating further information from him regarding the use of these medicines. Medication was seen to be administered appropriately. Staff who have the responsibility for administering medication had participated on a distancelearning course and further training was scheduled to take place in a few weeks time. This would ensure that staff were up to date with their knowledge regarding medication, its storage and administration. The Old Galleries DS0000022115.V300862.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by the home’s complaints procedure and staff who have received appropriate training regarding the protection of vulnerable adults. EVIDENCE: Old Galleries has an appropriate complaints procedure. Residents who were spoken to said that if they wanted to make a complaint or raise a concern they would be confident in approaching the management of the home. A copy of the complaints procedure was clearly displayed on the notice board, ensuring that residents and visitors were aware of how to make a complaint. Entries on residents’ files showed that the complaints procedure had been read and explained to them with residents signing to confirm this. The Old Galleries DS0000022115.V300862.R01.S.doc Version 5.2 Page 17 The manager of the home has himself attended training relating to the protection of vulnerable adults. This was arranged by Devon Social services and having attended it, he is now able to train the staff group at Old Galleries. All staff have now had training relating to the protection of vulnerable adults which has included pre course reading material and watching the ‘No Secrets’ training video. Staff have also attended training courses which instruct them in appropriate intervention techniques, should these be required. The Old Galleries DS0000022115.V300862.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a well-maintained environment which meets their needs. EVIDENCE: Old Galleries is situated off the High Street in Bideford. It is a large terraced property with a front door onto the High street. Its position means that residents can easily access the facilities of Bideford due to the home’s central location in an area which is primarily of shops and cafes. The home affords all residents single occupancy rooms. Residents are free to personalise their bedrooms according to their individual choice. The Old Galleries DS0000022115.V300862.R01.S.doc Version 5.2 Page 19 The premises are spacious and are centrally heated with the exception of the front lounge, which is heated when required. There are large communal areas comprising a lounge, dining room, further dining area and a kitchen. Residents can freely access all communal areas with the exception of the kitchen which can only be accessed when staff are present. This was explained as being for the safety of residents and beverage making equipment was available in the dining area for residents to use if they wanted a drink. The access of the home would make it unsuitable for anyone who had profound physical disabilities, but it is suitable to the needs of those who currently reside there. The home also has an enclosed and private rear garden which is accessible to residents. Residents spoken to said that they liked their rooms and that they liked living at Old Galleries. They were seen to be able to access all areas of the home, with the exception of the kitchen, unless supervised. Residents had personalised their rooms and all who wanted keys and could manage them had keys to both the front door of the home and to their own rooms. The décor is of a good standard and on the day of the inspection the home was seen to have a good standard of hygiene and cleanliness. The Old Galleries DS0000022115.V300862.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is staffed to meet the basic needs of its residents Residents are protected by the home’s recruitment procedure. Residents are supported by a staff team which receives appropriate training to ensure that the needs of residents can be met. EVIDENCE: At the commencement of the inspection there was one staff member on the premises who was later joined by the proprietor and the Head of Care. Most residents were out in the community and only two were present at the start of the inspection. Most residents at Old Galleries live an independent lifestyle, The Old Galleries DS0000022115.V300862.R01.S.doc Version 5.2 Page 21 which makes the staffing levels at Old Galleries adequate in meeting the needs of those currently resident there. In instances where residents need support to access the community, staff are made available for this for small groups. An example of this was a staff member being rostered on duty to enable another staff member to accompany residents to a club in the evening. In instances where one to one support is needed, additional staff are provided, however some residents are charged for this support. The home needs to reflect the charging of these fees in its Statement of Purpose and care plans. When asked, support staff were able to show rotas which showed which support staff were on duty. As at the previous inspection, these rotas did not show what hours managers are available. This was discussed with the proprietor who was able to show a record of the hours worked by the management which was kept separate from the other rotas and not available to support staff. The proprietor said this system was used as a way of being able to monitor the care in the home by coming on duty at different times. The home operates an appropriate recruitment procedure. Three files were inspected. One was found to contain one reference rather than the two required. The proprietor considered that there was another reference but was unable to locate it at the time of the inspection but agreed to take appropriate action to redress this. All other files contained the two references and police checks. Where workers came from abroad, as well as police checks from this country, there were police checks from their country of origin. In addition to having police checks upon being recruited, staff also sign, after certain periods of employment, that they have not had any further convictions. Staff training was discussed with the management of the home. The registered manager has got details regarding the Learning Disability Framework Accreditation (L.D.A.F) induction and in future any new staff will receive this induction. This induction is specifically for staff working with residents who have a learning disability. Inspection of staff files showed that currently staff receive an induction which covers items such as communication, medication and healthcare, reference to the Statement of Purpose, and Health and Safety issues. This ensures that staff have the information required to ensure that they can safeguard residents and do their job appropriately. The home has a commitment to NVQ training and is registered with the Autistic Accreditation Society, which is to provide specialist training for staff at the home. Information supplied by the assistant manager shows that of the eight care staff, seven have attained NVQ level 2, which is a good level of trained staff. The Old Galleries DS0000022115.V300862.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run by an experienced management team. Residents would benefit from the quality assurance system being more regularly and consistently applied so that more up to date opinions could guide the development of the service. The home’s policies and procedures and maintenance of equipment premises ensure that the health, safety and welfare of residents and staff is protected. The Old Galleries DS0000022115.V300862.R01.S.doc Version 5.2 Page 23 EVIDENCE: The registered manager has considerable experience of working with people who have learning disabilities and on the day of the inspection was away participating on a training course. The home does have a system of quality assurance. This comprises questionnaires, which were addressed to staff and stakeholders respectively. The questionnaires which were forwarded to staff contained questions regarding how they regarded the quality of care given to residents, the training on offer, support structures and the general management of the home. This had been circulated to staff in January 2005 and three responses had been received. Further questionnaires had been circulated to stakeholders. This group included the family and friends of residents and included questions about the helpfulness of staff and managers and general opinions about the home. These questionnaires were however not dated. Whilst, at the time of the inspection Quality Assurance questionnaires compiled by residents were not available, the management did refer to the fact that residents meetings were held, at which residents could let their opinions regarding the home be known. Prior to the inspection the registered manager completed a questionnaire for the Commission for social Care Inspection. This contained details which showed that the home had the necessary policies and procedures to protect staff and residents and that within the home, premises and equipment was maintained in an appropriate manner to ensure the safety and well being of staff and residents. The Old Galleries DS0000022115.V300862.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X The Old Galleries DS0000022115.V300862.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations Where a resident’s needs, identified in a care plan, have to be met through use of additional staffing, funded by that resident, this should be recorded in his/her contract and agreed, wherever possible at the commencement of a placement. Quality assurance systems should take account of the comments from residents and other stakeholders at least on an annual basis. A report summarising these findings and any necessary action, should be compiled and shared with the Commission, residents and other stakeholders. 2. YA39 The Old Galleries DS0000022115.V300862.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Devon Area Unit D1 Linhay Business Park Ashburton Devon TQ13 7UP 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 The Old Galleries DS0000022115.V300862.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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