Care Home: Ashcombe Court

Similar services:

• 2 Perhaver Park
• The Vicarage
• St George`s
• 5 Seafield Road
• Radfords
• Trevaylor Manor
• Honeybourne House

What the care home does well Residents spoken to said that what they like about the home is the way they are encouraged to make their own decisions. They also praised the way in which staff provided a very supporting and caring service. One relative said staff all demonstrated a caring and cheerful approach that meant a lot. Residents` benefit from care that is person centred and treats them all as individuals. This includes the support to access the local community and to maintain appropriate meaningful relationships with family and friends. Staff also provide a supportive role in assisting residents to attend hospital appointments and maintain their emotional wellbeing. The home demonstrated a caring and supportive role in the care provided to a resident with terminal illness that was highly commendable. What has improved since the last inspection? Since the last inspection the manager has completed the registration process with the Commission. The management of the home clearly involves residents and staff. The storage of medication has improved as a lockable approved cupboard has been provided.Staff have received training in the safeguarding of vulnerable adults. They are aware of the local policies and procedures and the action to take if an allegation of abuse was made. Staff have developed their skills to meet the needs of the current resident group. They also access training or guidance relevant to specific needs, and individual clinical training days have been introduced. A review of the induction programme for new staff means it is now in line with the General Social Skills Council. What the care home could do better: No requirements were made as a result of this inspection. One recommendation has been made as the complaints procedure directed people to the Taunton rather than the Bristol Office. The provider needs to review the procedure so it directs people to the correct office. CARE HOME ADULTS 18-65 Ashcombe Court 17 Milton Road Weston Super Mare North Somerset BS23 2SJ Lead Inspector Juanita Glass Unannounced Inspection 4th January 2008 09:30 Ashcombe Court DS0000064879.V354801.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 Ashcombe Court DS0000064879.V354801.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. Ashcombe Court DS0000064879.V354801.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashcombe Court Address 17 Milton Road Weston Super Mare North Somerset BS23 2SJ 01934 626408 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) ashcombecourt@tracscare.co.uk suehullin@tracscare.co.uk Tracscare Group Ltd Post Vacant Care Home 7 Category(ies) of Learning disability (7), Mental disorder, registration, with number excluding learning disability or dementia (7) of places Ashcombe Court DS0000064879.V354801.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered manager to commence the Registered Manager`s Award by December 2005 13th March 2007 Date of last inspection Brief Description of the Service: Ashcombe Court is a care home providing personal care for up to seven persons with a mental health problem or learning difficulty. The care home is a large detached Victorian dwelling situated in a quiet residential area of the town with a garden to the front and an enclosed decked area for outdoor activities at the rear. There are four car parking spaces to the side of the property. The seven bedrooms are all single accommodation and include en-suite shower. The accommodation is over two floors reached by stairs. There is no lift facility, however the home has wheelchair access throughout the ground floor and two ground floor rooms suitable for clients’ who have impaired mobility. There is level access on each floor. The home is compliant with the Disability Discrimination Act. Communal facilities consist of a large sitting room, dining room, smoking room kitchen and laundry. Clients have open access to the kitchen but are supervised when using the laundry. The home is conveniently situated for local facilities such as shops, GP practice etc. Experienced carers who are able to support clients to access community facilities and pursue their social, vocational and leisure interests staff the home. The fees are £1600 to £2000.00 per week with additional charges being made for hairdressing, chiropody, non-therapeutic activities, reading materials, cigarettes and newspapers. Ashcombe Court DS0000064879.V354801.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection took place over one day in the presence of the deputy manager. Five people were living in the home at this time. Two people agreed to share their experience of living in Ashcombe Court. Written surveys had been returned to the commission, three were from people living in the home and one was from a relative. To gather further evidence to support the findings for this inspection, we (the commission) carried out a review of two care plans for people living in the home. We also reviewed documentation maintained for the day-to-day running of the home and spoke to staff. The documents reveiwed included staff personnel, training and supervision records, service records, policies and procedures and records for health and safety issues. We also carried out an audit of the administration and storage of medication. What the service does well: What has improved since the last inspection? Since the last inspection the manager has completed the registration process with the Commission. The management of the home clearly involves residents and staff. The storage of medication has improved as a lockable approved cupboard has been provided. Ashcombe Court DS0000064879.V354801.R01.S.doc Version 5.2 Page 6 Staff have received training in the safeguarding of vulnerable adults. They are aware of the local policies and procedures and the action to take if an allegation of abuse was made. Staff have developed their skills to meet the needs of the current resident group. They also access training or guidance relevant to specific needs, and individual clinical training days have been introduced. A review of the induction programme for new staff means it is now in line with the General Social Skills Council. 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. Ashcombe Court DS0000064879.V354801.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 Ashcombe Court DS0000064879.V354801.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 and 4 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Prospective residents benefit from appropriate and sufficient information to help them make an informed decision about moving into Ashcombe Court. They also benefit from the chance to visit the home and test drive before moving in. EVIDENCE: The care plans for two residents were reviewed. They both contained very detailed assessments of their needs. A clinical support nurse who has the specific knowledge and skills to assess people with mental health problems carries out the assessment. The home manager is also involved in the preadmission assessment as she has the knowledge about the home dynamics specific to Ashcombe Court. Following the care assessment the manager offers the prospective resident a trial visit. This can be for as long as a week to allow the person the chance to get to know staff, residents and the local area. The manager then involves staff in the final decision as to whether the home is suitable for that person and can meet their needs. If current residents want to they can also let staff know how they would feel about the placement. One person living in the home said they felt they had been given plenty of information. They felt the chance Ashcombe Court DS0000064879.V354801.R01.S.doc Version 5.2 Page 9 to visit and test drive the home was very important and had helped them make the decision without leaving any unanswered questions. Since the last inspection the admission procedure has been revised so that the manager and staff are more involved in the assessment and admission process. This ensures that the needs of people moving into the home can be met appropriately by staff with the relevant skills and knowledge in the care of people with diverse mental health problems. Ashcombe Court DS0000064879.V354801.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 benefit from a service, which involves them in the planning of their care and lifestyles. They are encouraged to take control of their own lives including taking risks whilst living in a supportive community. EVIDENCE: Two of five care plans were reviewed. Each care plan was very detailed and contained comprehensive evidence of peoples diverse needs. They were individual to the person and showed evidence of being agreed with that individual. Signed care plans, reviews and agreed risk assessments were all seen. Both plans also contained a personal portrait. They were headed what I do, dont do and who I am. These enable residents to say what they like and dislike, what their hobbies and interests are and how they would prefer to live at Ashcombe Court. Ashcombe Court DS0000064879.V354801.R01.S.doc Version 5.2 Page 11 The care plans are a working record and the daily record described clearly staff and resident interactions. They were very clear and easy to understand, and included a copy of the homes complaints and confidentiality policies. These had been signed and agreed by the residents. Activities are agreed on a weekly basis this ensures an individual structured plan does not conflict with other peoples plans for the week. Staff were observed throughout the inspection supporting residents in making decisions about their day i.e. going shopping, making meals or following an interest. Residents, who have expressed a wish to have a pet, have been supported to care for the animal of their choice. Residents said they felt that they were able to make their own decisions about their lifestyle and they also felt they were supported by staff to attain agreed goals, such as lifestyle skills, building relationships and accessing the local community. One written survey said being able to make my own decisions is why I like it here. Ashcombe Court still operates a locked door policy due to the legal status of two residents under the Mental Health Act 1983. Residents do have their own front door keys following a risk assessment and are free to come and go as long as staff are kept informed. Two residents spoken to said this was not an issue for them, they felt they had the freedom to follow the lifestyle they wished. Ashcombe Court DS0000064879.V354801.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 benefit from a philosophy of care that enables them to develop life skills and take part in planned activities within the home and the local community. They are also enabled to maintain contact with family friends and to develop relationships. EVIDENCE: Care plans contained an activities program for each individual. These are agreed weekly with the resident enabling them to follow a programme specific to their needs and ability. Activities planned included life skills development such as shopping, preparing their own meals and keeping their rooms tidy. Residents with pets are enabled to maintain a safe, clean and caring environment for them with support from staff. The weekly activities plan also includes activities in the home as well as the local community. One resident is looking for voluntary work with animals, Ashcombe Court DS0000064879.V354801.R01.S.doc Version 5.2 Page 13 whilst others enjoy going for walks, musical sessions, arts and crafts, meals out and a game of pool. One resident said they were particularly glad to be able to follow the progress of their football team on the digital TV. One written survey said they were pleased to live in a home where they could have their animals and Sky TV. Residents spoken to said they had plenty to do. Care plans showed an element of flexibility enabling people to change their minds or take up a new hobby. Staff also encourage residents to follow educational and developmental courses in resource centres in Weston Super Mare. The provision of an annual holiday was discussed as this had been raised at the last inspection. Residents have been asked about their preferences. The most popular choices are for days out rather than a week away. The reasons given for this varied such as the reluctance to stay in a strange place, meeting strange people or even going to crowded places. The home therefore supports people in taking day trips, going to stay with family or friends or having a breakaway if they so request. Residents are encouraged to eat a healthy and well balanced diet. Personal preferences are recorded. Residents said they help prepare meals supported by staff. Special dietary requirements can be accommodated and residents are assisted in understanding how to manage their diets. Ashcombe Court DS0000064879.V354801.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, 20 and 21 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents benefit from health care support that is person centred and includes specialist input from health care services. Medication policy and Administration is efficient and residents are enabled to manage their own medication where possible. The home supports residents in making and following end of life decisions EVIDENCE: Care plans and daily records clearly showed evidence of residents being assisted to access health care services either for emotional or physical needs. There was evidence of visits to dentists, opticians, community psychiatric services and the residents own GP. One member of staff is experienced in counselling and provides emotional support in one-to-one sessions when needed. This continues to give people living in the home an opportunity to discuss any concerns or fears they are experiencing. Residents are also able to receive emotional and psychological support from health care professionals at hospital visits. Ashcombe Court DS0000064879.V354801.R01.S.doc Version 5.2 Page 15 Residents spoken to said the care and support they receive from staff was always respectful and appropriate. They said they felt they could talk to staff about both emotional and physical needs at any time. There is a detailed medicines policy and procedure in place. All care staff receive both in-house and distance training in the receipt, storage and administration of medication. They then carry out five observed practices before being able to administer medication themselves. Two members of staff are always present during the administration of medication. Since the last inspection a suitable medication cabinet has been obtained and all medication is now stored in this cabinet in a locked room. Residents care plans showed clear guidelines including triggers and warning signs to be aware of before using ‘as required’ medication. Care plans also contained an anti-psychotic medication side effect chart, which monitors whether residents are experiencing unwanted side effects to their medication. Each resident has a self-medicating risk assessment completed. This supports the decision to either support the resident in managing their own medication or for staff to manage it for them. An audit of medication in the home revealed no errors. Ashcombe Court recently supported a resident with a terminal illness to remain in the home, as was their wish. They arranged for support from the local hospice and district nurse service to enable this resident to end their life in the home of their choice. Following this experience staff are supporting other residents in making end of life decisions. One resident said it was a good idea. All staff and residents were offered bereavement counselling following the death of the resident who was terminally ill. Ashcombe Court DS0000064879.V354801.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 benefit from an open culture that allows them to express their views and concerns in a safe and understanding environment. The policies and procedures for safeguarding adults are available and give clear specific guidance to those using them. Staff have attended training in safeguarding adult procedures. EVIDENCE: Ashcombe Court has a detailed complaints policy and procedure. Copies are displayed in the dining room, smoking room and provided with the service user guide. The policy currently provides the address for Taunton rather than the Bristol Office; this needs to be up dated. Residents spoken to and written surveys indicated that they felt listened to and their needs and wishes understood. All residents spoken to said they knew whom to talk to if they wished to make a complaint. A monthly residents meeting is held and issues raised are then copied into the staff meeting agenda, residents are also offered the opportunity to attend the staff meetings. Since the last inspection staff have attended training in safeguarding adults, they are aware or both the homes and local policies and procedures to follow in the case of an allegation of abuse. Ashcombe Court DS0000064879.V354801.R01.S.doc Version 5.2 Page 17 Ashcombe Court DS0000064879.V354801.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 excellent This judgement has been made using available evidence including a visit to this service. Residents benefit from a homely, safe and well maintained environment that is decorated to meet their personal preferences. EVIDENCE: Ashcombe Court is a well lit, well decorated home, providing comfortable communal areas and a separate smoking room which has an air vent to minimise air pollution. Outside areas are accessible with decked areas to sit in warmer weather. One resident agreed to show us his room. He very proudly announced that ‘staff pulled all the stops out when they decorated my room for me.’ The deputy manager confirmed that rooms would be decorated to meet the preferences of the individual, and that personal possessions could be bought in. Ashcombe Court DS0000064879.V354801.R01.S.doc Version 5.2 Page 19 A laundry area is provided and residents are assisted to manage their own laundry. The kitchen area was clean and tidy and accessible to all residents. Ashcombe Court DS0000064879.V354801.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents benefit from an appropriate number of staff who have the right skill mix and training to adequately meet their needs. They are also protected by the robust recruitment procedures observed by the home. EVIDENCE: The staffing rota showed that there is an appropriate number of staff on duty in the home at any time day or night. Residents said that there was always plenty of staff in the home to support them. The staffing ratio for people qualified to NVQ level 2 or above exceeds the stated 50 required as 69 of the staff at Ashcombe Court has a relevant qualification. Training records showed that staff have attended all mandatory training as well as training in areas specific to the needs of the current resident group. Details of specific conditions were evidenced in care plans. The deputy confirmed that they access information via the Internet, professional journals and by training sessions provided by the clinical support nurses when they visit the home. Ashcombe Court DS0000064879.V354801.R01.S.doc Version 5.2 Page 21 All staff receives formal supervision every 8 weeks this is recorded in their personnel files they also meet as a team monthly. All new staff receives weekly supervision whilst working through the induction process. A review of the personnel records for the most recently employed member of staff showed that residents are protected by a robust recruitment procedure. All the required documentation was available showing that a POVA 1st, CRB and 2 references are obtained before a new member of staff commences work. Ashcombe Court DS0000064879.V354801.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. Residents benefit from a management style that is open and approachable, which encourages them to have a say in the day-to-day running of the home. They are confident that their views and opinions are listened to and valued. Residents and staff are protected by satisfactory health and safety policies and procedures. EVIDENCE: The Manager has approximately 6 years experience in the care of people with Mental Health Problems and acquired brain injury. She has completed the managers’ registration with the Commission for Social Care Inspection. The manager is supported by the Deputy Manager who also has experience in the care of people with Mental Health problems, Learning Disabilities and Drug and Ashcombe Court DS0000064879.V354801.R01.S.doc Version 5.2 Page 23 Alcohol Abuse. Both are currently in the process of completing the Registered Managers Award. Residents spoken to said they felt they could talk to any member of staff including the manager. They also said she was very open and approachable, providing advice and support. An annual ‘client quality questionnaire’ is sent to all people in the home this forms the basis for a corporate report. Managers are then asked to complete an action plan to address the identified comments. As well as residents surveys the home sends questionnaires to outside stakeholders and staff. This means that the manager can get a clear view of how people see the service is being delivered. Residents are also invited to a focus day, which is run independently of the organisation. This enables them to feel free to comment on issues they may be reluctant to raise with people they know and is good practice. The implementation of health and safety within the home was satisfactory. All residents have personal risk assessments. Generic risk assessments are in place and reviewed regularly. A review of the firelog showed all tests, training and drills were being carried out to the Avon and Somerset Fire Brigade guidelines. All service records were available for inspection and up-to-date. Ashcombe Court DS0000064879.V354801.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 3 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 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 3 X X 3 X Ashcombe Court DS0000064879.V354801.R01.S.doc Version 5.2 Page 25 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA22 Good Practice Recommendations The provider needs to review the complaints procedure to direct people to the correct CSCI address. Ashcombe Court DS0000064879.V354801.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Ashcombe Court DS0000064879.V354801.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!