Care Home: Coachmans Drive (21)

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What the care home does well Before a new person moves into the home the manager makes sure that she gets information on what the person needs are from a social worker or other professional person. This is so that the manager knows what the new person needs and can decide if their needs can be met at the home. Each person who lives at the home has a care plan. These have a lot of information in which tells the staff what they need to do to support the person. People living at the home are supported to get involved with some of the household tasks and use their skills. Staff support people living at the home to visit their doctor, dentist, nurse, optician and other important appointments on a regular basis. Staff are goodCoachmans Drive (21)DS0000025240.V378457.R01.S.docVersion 5.3at taking care of medication and support people well with their medication. The home is relaxed and people are choosing their own daily routines such as what time to get up in the morning and what time they go to bed. People are included in meetings about the home. The staff team are well trained and are confident that they can support people well. The manager makes sure that the home is comfortable, nicely decorated, safe and clean. What has improved since the last inspection? There has been more staff training in the past 12 months. Medication is now better managed and new ways of recording medication have been started. There have been improvements to the home environment and some redecoration. The home now has a qualified manager who is registered with us. What the care home could do better: There is information on the home called the `service user guide`. This could be written in different ways so that people can understand it better and it could have better information in which is more important to the people living at the home. People living at the home could have greater opportunities to try new activities and be involved in activities of interest to them on a more regular basis. Key inspection report CARE HOME ADULTS 18-65 Coachmans Drive (21) 21 Coachmans Drive Croxteth Park Liverpool Merseyside L12 0NX Lead Inspector Debbie Corcoran Key Unannounced Inspection 12th November 2009 09:00 Coachmans Drive (21) DS0000025240.V378457.R01.S.doc Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Coachmans Drive (21) DS0000025240.V378457.R01.S.doc Version 5.3 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Coachmans Drive (21) DS0000025240.V378457.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service Coachmans Drive (21) Address 21 Coachmans Drive Croxteth Park Liverpool Merseyside L12 0NX 0151 220 9729 9999 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) www.c-i-c.co.uk. Community Integrated Care Nicola Mary Trousdale Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Coachmans Drive (21) DS0000025240.V378457.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD The maximum number of service users who can be accommodated is: 3 Date of last inspection 2nd September 2008 Brief Description of the Service: 21 Coachmans Drive is an accessible three bed-roomed bungalow that is situated in the Croxteth Park area of Liverpool. At present there are only two people living in the home. The service is provided by Community Integrated Care and is registered to provide personal care and support to three adults with a learning disability. The property has a large lounge that contains a dining area, a bathroom with bathing aids, kitchen and an office. There is a private, enclosed garden to the rear of the home and an open plan front garden and driveway. The home has a mini bus and there is also a local bus service within walking distance. The fees for residing at the home depend on the individual needs of the person and should be sought from the service provider. Coachmans Drive (21) DS0000025240.V378457.R01.S.doc Version 5.3 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. The manager did not know that we were going to visit the home before we arrived. During the visit both of the people who live at the home were met. We also sent surveys to people living at the home and asked for their views on the service. A member of the care staff team and the manager were spoken with during the visit. Care plans, staff records, health and safety records and other relevant records were looked at. A tour of the home was carried out and all areas were checked. The manager returned a self assessment of the service and we have used some of the information in this help us decide how the home is doing. Surveys were sent to staff before the visit for them to make comments on the home. What the service does well: Before a new person moves into the home the manager makes sure that she gets information on what the person needs are from a social worker or other professional person. This is so that the manager knows what the new person needs and can decide if their needs can be met at the home. Each person who lives at the home has a care plan. These have a lot of information in which tells the staff what they need to do to support the person. People living at the home are supported to get involved with some of the household tasks and use their skills. Staff support people living at the home to visit their doctor, dentist, nurse, optician and other important appointments on a regular basis. Staff are good Coachmans Drive (21) DS0000025240.V378457.R01.S.doc Version 5.3 Page 6 at taking care of medication and support people well with their medication. The home is relaxed and people are choosing their own daily routines such as what time to get up in the morning and what time they go to bed. People are included in meetings about the home. The staff team are well trained and are confident that they can support people well. The manager makes sure that the home is comfortable, nicely decorated, safe and clean. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Coachmans Drive (21) DS0000025240.V378457.R01.S.doc Version 5.3 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 Coachmans Drive (21) DS0000025240.V378457.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People do not move into the home without the manager being aware of the persons needs and confident that these can be met. EVIDENCE: A statement of purpose and service user guide are available to provide people with information on the services and facilities provided at the home. This includes information on the core values and purpose of the service, the admissions criteria, the philosophy of care including how equality, diversity and individuality are promoted, the staffing and management, how to make a complaint, what activities take place and how people are consulted with. The manager should update the statement of purpose to reflect the change of manager. Alongside this, the level of information in the service user guide should be reviewed and the manager should aim to produce the guide in alternative formats more user friendly for the people using the service. One new person has moved into the home since the last inspection visit. The manager was asked to describe the circumstances around this persons move and how this was managed. The manager stated that an assessment of needs was carried out with the person, an advocate was involved in the move and Coachmans Drive (21) DS0000025240.V378457.R01.S.doc Version 5.3 Page 9 numerous phased visits were made to the service including overnight stays and weekend stays. A copy of the persons assessment of needs was not available at the time of the visit. Along with general assessment information risk assessments are carried out and these identify potential risks to people using the service. Coachmans Drive (21) DS0000025240.V378457.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9, People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Each of the people using the service has an individual support plan which provides staff with guidance on what the persons needs are, how these should be met and how the person communicates choices. EVIDENCE: Care plans for both of the people living at the home were looked at. These were found to be of a very good standard and were clear, informative and easy to follow. The plans included information on the needs of the person in areas such as their mental health, physical health, health care and personal care. The level of information in the care plans was well pitched and this ensures staff are provided with important information on the needs of the person. Each of the people living at the home also has an Essential Lifestyle Plan (ELP). These plans include information on the person’s skills and needs, daily Coachmans Drive (21) DS0000025240.V378457.R01.S.doc Version 5.3 Page 11 routines, likes and dislikes, health, communication skills and needs, information on what is essential to support them successfully, and what is important to know. Together the plans include detailed guidelines as to how to support the person with all aspects of their personal care, physical care and health, and emotional wellbeing. The plans also showed some goal setting and evaluation of how these are being achieved. We also saw that one person had a communication dictionary which provided staff with guidance on how the person concerned communicates their needs, wishes etc. Risk assessments are carried out in relation to the support provided to each of the people living at the home and these were viewed. The risk assessments identify potential hazards to the person’s safety and well being and include detailed guidelines as to how to then manage the risk or prevent the risk from occurring. The risk assessments cover different aspects of the persons Coachmans Drive (21) DS0000025240.V378457.R01.S.doc Version 5.3 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): This is what people staying in this care home experience: 11, 12, 13, 14, 15, 16, 17 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service are supported with their personal development and are encouraged to choose their food and meals and are encouraged to eat a healthy balanced diet. EVIDENCE: During discussions with staff they described some of the activities which people living at the home are supported with. These are quite limited and do not occur on a regular basis. The manager is currently looking to ensure people have better opportunities for recreational activities and we would recommend that this continues so as to improve peoples social and recreational experiences. Essential lifestyle plans include a good level of information on the person’s strengths and needs and staff are therefore clear as to how to promote and Coachmans Drive (21) DS0000025240.V378457.R01.S.doc Version 5.3 Page 13 encourage these. A member of staff gave us examples of how they encourage the people living at the home to use their skills. Records relating to people living at the home include information on the people who are important to them and include contact details for their relatives, friends and relevant others. We could see from these that staff are being proactive in promoting and facilitating relationships. In assessing the diet and meals available to people living at the home menu records were looked at and the availability and storage of food was checked. These indicated that the people living at the home have a good choice and variety of food and meals. People living at the home are encouraged to make choices of meals through a variety of means of communication and staff know each person’s likes and dislikes. This information is also well documented as information on people’s likes, dislikes, strengths and needs regarding food, meals and eating are recorded in their care plans and essential lifestyle plans. Coachmans Drive (21) DS0000025240.V378457.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home are well supported with their personal, emotional, physical and health care needs and medication is well managed. EVIDENCE: Each of the people living at the home has a care plan and these include a good level of information on how to support the person with their emotional and physical health and well being. Where a person requires support with personal care their plans include detailed information on the person’s needs, skills, choices and routines with this. Each person living at the home has an Essential lifestyle plan and these by their nature guide staff on how to support people using the service with their emotional and psychological well being. Records showed that people living at the home are well supported to remain healthy and to attend health related appointments on a regular basis. For Coachmans Drive (21) DS0000025240.V378457.R01.S.doc Version 5.3 Page 15 example they are supported to see a GP, district nurse, dentist, optician etc on a regular basis. People are also supported to see other health professionals as appropriate to their needs. Each person living at the home has a health action plan and care plans also include a good level of information on the persons needs with health care. These are reviewed on a regular basis. We looked at how medication is being managed. In doing this we checked and storage, recording, stock and auditing of medication. These showed that medication is safely managed. The manager has implemented some new procedures for managing medication. Staff have been provided with medication training. Medication records included information on the persons medication such the reason it is prescribed and any possible side effects. The manager reported that medication is audited on a weekly basis. The manager has recently carried out an assessment of staff competence in administering medication. Coachmans Drive (21) DS0000025240.V378457.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Policies procedures and practices are in place for dealing with complaints and for aiming to protect people against abuse or neglect. EVIDENCE: The home has a complaints procedure which is time scaled appropriately and includes contact details for the Commission. The statement of purpose and service user guide for the home include brief information on how to make a complaint and give an overview of how complaints are dealt with. However, this needs to be reviewed and updated so that it informs the reader that a complaint can be forwarded to the Commission as opposed to how it reads with the Commissions address only. Staff appear to know the needs of the people living at the home well and this therefore indicates that they are aware of people’s needs and choices and listen to people when these need to be changed. The home has an Adult protection procedure. This includes information on responsibilities for contacting relevant authorities. Care staff have been provided with training in adult protection. The manager was asked how she would respond to an allegation of abuse and she was able to provide an appropriate response to this. Coachmans Drive (21) DS0000025240.V378457.R01.S.doc Version 5.3 Page 17 A record of key events is maintained for example incident reports and accident reports. The system for recording peoples monies was checked. A random sample of records for this showed that the system does aim to safeguard the people living at the home. The manager reported regular audits of this. Coachmans Drive (21) DS0000025240.V378457.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 28, 29, 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are provided with a homely, comfortable, safe and well maintained home environment. EVIDENCE: Coachmans Drive is a three bed detached bungalow. The home accommodates two people at any one time although registered for three people. The smallest bedroom is used as a staff office. The home is fully accessible and fitted with aids and adaptations as appropriate to the needs of the people living there. Each person has their own bedroom and these were looked at and found to be well presented. Furnishings and fittings were noted to be of a good standard. Bedrooms were personalised with peoples own belongings. Coachmans Drive (21) DS0000025240.V378457.R01.S.doc Version 5.3 Page 19 The home has been redecorated throughout since the last inspection visit and the manager reported that a new kitchen is scheduled to be fitted within the next few weeks. The home has a large rear garden which is well maintained and provides a good amount of outdoor space for peoples use. The home is comfortable, clean and well maintained. The home has health and safety practices and procedures which are aimed at ensuring the home is clean and free from hazards to the health and safety of people living at the home, staff and visitors. Coachmans Drive (21) DS0000025240.V378457.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff appear to know the needs of the people living at the home well. Staff are well supported, and staffing levels allow for a good level of one to one support for people living at the home. EVIDENCE: The manager has carried out an analysis of staff training and planning is in place to meet the identified training needs of staff and to ensure that staff are provided with training in core health and safety related skills. Staff files showed that they have been provided with training in topics such as medication management, supporting people with challenging behaviour, food hygiene, health and safety, fire safety, first aid, adult protection and moving and handling. The manager advised that she has arranged for staff to be provided with equality and diversity training and refresher training in moving and handling people. Coachmans Drive (21) DS0000025240.V378457.R01.S.doc Version 5.3 Page 21 New staff undergo a period of induction during which they are provided with training in core health and safety related topics such as those mentioned above. There are a total of 5 support workers and 3 of these have attained a relevant qualification. This means the target for 50 of the staff team to have attained a relevant qualification has been met and exceeded. There have been two new members of care staff employed at the home since the last inspection visit. The recruitment and selection procedures in relation to the new staff were looked at and discussed with the manager. This showed us that all relevant pre employment checks had been carried out prior to their employment and this is done as an aim to safeguard the people living at the home. Discussions with a member of care staff indicated that staff are supporting the aims and objectives of the home in encouraging people to make choices, use their independent living skills as appropriate to their needs, and use their local community. Staff are provided with regular supervision meetings and team meetings also take place on a regular basis. These meetings provide an opportunity for staff to explore their practice, discuss issues which may affect the service provided to people living at the home, explore new ways of working and to make and communicate decisions as to how to develop the service. Coachmans Drive (21) DS0000025240.V378457.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 42 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well managed and is run in the best interests of the people living there. Practices are in place which protect the health, welfare and safety of people living at the home. EVIDENCE: The manager has recently become registered as manager with the Commission. The manager reported that they have attained a relevant qualification. The manager has introduced some good practices and is actively planning to ensure the service meets the needs of the people living at the home. The Coachmans Drive (21) DS0000025240.V378457.R01.S.doc Version 5.3 Page 23 manager promotes person centred care and is planning to increase the opportunities for new experiences for people living at the home. The home is well organised and all required information was readily at hand. The home appears to be run in the best interests of the people living there. There is a quality assurance process which includes regular visits and audits from a representative employed by CIC. Reports of these visits were available. The home has numerous policies and procedures in relation to health and safety and staff are provided with training in core health and safety related skills. A sample of records of fire and health and safety checks were looked at and found to be up to date. The only area we noted for address is for the manager to implement the recommendations regarding better fire safety as identified during a recent fire safety check. A safe working practice risk assessment is in place. These practices demonstrate that the health, safety and welfare of people living at the home, staff and visitors are protected. Coachmans Drive (21) DS0000025240.V378457.R01.S.doc Version 5.3 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 2 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 3 25 3 26 3 27 X 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 3 12 2 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 3 3 3 X 3 x Version 5.3 Page 25 Coachmans Drive (21) DS0000025240.V378457.R01.S.doc Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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 YA1 Good Practice Recommendations The statement of purpose and service user guide should be reviewed and updated so at to ensure that people are provided with accessible and up to date information on the service. People should be given the opportunity to experience a greater variety of activities on a regular basis in line with their needs and wishes. The complaints procedure should be reviewed and updated to ensure people are provided with accurate information on making a complaint and for referring complaints information on. Recommendations made following a recent fire safety check should be actioned and we should be notified when DS0000025240.V378457.R01.S.doc Version 5.3 Page 26 2. YA14 3. YA22 4. YA42 Coachmans Drive (21) these have been completed. Coachmans Drive (21) DS0000025240.V378457.R01.S.doc Version 5.3 Page 27 Care Quality Commission North West Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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