Care Home: Ellenborough Court

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What the care home does well People living in the home indicated in their surveys that they were happy with the care they received form `nice kind and caring staff.` The staff at Ellenborough Court provide a level of support for people living there that enables them to live as `normal` a life as possible within a care setting. Respecting their individuality, likes and dislikes which shows a clear understanding of the diverse needs of young adults and their need to be an individual with a say about the way they wish to live. Care planning is agreed and person centred supporting people to achieve their desired goals. The environment supports personal preferences with support provided in individual flats that are personalised to the person`s own designs and preferences. People are assisted to learn and acquire personal life skills to enable them to consider the possibility of moving on to supported living. What has improved since the last inspection? This was the first inspection following registration What the care home could do better: No requirements were made we recommended that staff supervision is formally recorded to show that staff receive appropriate support enabling them to continue to provide a good service for the people living in Ellenborough Court. CARE HOME ADULTS 18-65 Ellenborough Court 3 Ellenborough Cresent Weston-Super-Mare North Somerset BS23 1XL Lead Inspector Juanita Glass Unannounced Inspection 2nd October 2008 10:00 Ellenborough Court DS0000071852.V372794.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 Ellenborough Court DS0000071852.V372794.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. Ellenborough Court DS0000071852.V372794.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ellenborough Court Address 3 Ellenborough Cresent Weston-Super-Mare North Somerset BS23 1XL 01934 424 262 0845 094 3233 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.cts-homes.co.uk Community Therapeutic Services Ltd Dr David Wing Care Home 5 Category(ies) of Learning disability (5), Mental disorder, registration, with number excluding learning disability or dementia (5) of places Ellenborough Court DS0000071852.V372794.R01.S.doc Version 5.2 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 either gender whose primary care needs on admission to the home are within the following categories: Learning disability - (Code LD) 2. Mental disorder - (Code MD) The maximum number of service users who can be accommodated is 5. Date of last inspection First Inspection Brief Description of the Service: Community Therapeutic Services Ltd provides specialist residential care and accommodation for people with a wide range of learning disabilities and mental health needs. Ellenborough Court is a three storey Victorian property, which is within walking distance of Weston-super-Mare town centre. It is set back from the sea front and is next to a park. It offers self-contained individualised accommodation. The home is registered for 5 persons with the CSCI (Commission for Social Care Inspection). The age range is 18-65 years old and the registration category is for people with Learning Disabilities who may also have Mental Health difficulties. The home is able to offer services to men and women under these categories. Ellenborough Court does not provide nursing care but they can access the Community Nursing services if necessary. It consists of 5 self-contained and spacious flats, which are all fitted with their own bathrooms, living rooms and kitchens. All flats are fitted with smoke detectors, telephone and television aerial points. Ellenborough Court aims to provide a homely environment for People with Learning Disabilities. Taken from their statement of purpose some of their aims are: ‘To help our service users to not only be present in the community, but also Ellenborough Court DS0000071852.V372794.R01.S.doc Version 5.2 Page 5 acquire skills and participate to the fullness of their abilities. To help the service user to take a positive step towards more integrated social living and greater independence. To encourage service users to individualise their rooms by furniture, posters or pictures. To provide a stimulating environment while also providing space for quiet and calm. To provide regular outings into the community, including social outings, leisure, college, and vocational and voluntary access. To establish a clear care pathway from the time of referral. To achieve these objectives we utilise the Care Programme Approach, where necessary, and Person Centred Planning.’ (A full list of their aims and objectives is available on request from the home). Current fees range from £2485 to £3260 per week dependent on assessed need. Ellenborough Court DS0000071852.V372794.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use the service experience good quality outcomes. This inspection took place over one day and a total of five hours were spent in the home. To gather enough evidence to support our judgments for this inspection, we The Commission asked the service provider to complete an Annual Quality Assurance Assessment (AQAA). The AQAA is a self-assessment that focuses on how well outcomes are being met for people living in the home. It also gives us some numerical information about the service, and how they intend to maintain or improve outcomes for people using their service. We also looked at surveys returned to us by people living in the home and people with an interest such as relatives, social workers and GPs. We received 4 surveys, 2 from people living in the home and 2 from staff who work there. Once we had received this information we carried out a visit to the home and spoke to people living there and staff. Whilst in the home we also looked at documents maintained for the day-to-day running of the service. These included care plans, staff recruitment, training and supervision. Also records relevant to the administration of medication, service records and health and safety. What the service does well: People living in the home indicated in their surveys that they were happy with the care they received form ‘nice kind and caring staff.’ The staff at Ellenborough Court provide a level of support for people living there that enables them to live as ‘normal’ a life as possible within a care setting. Respecting their individuality, likes and dislikes which shows a clear understanding of the diverse needs of young adults and their need to be an individual with a say about the way they wish to live. Care planning is agreed and person centred supporting people to achieve their desired goals. The environment supports personal preferences with support provided in individual flats that are personalised to the person’s own designs and preferences. Ellenborough Court DS0000071852.V372794.R01.S.doc Version 5.2 Page 7 People are assisted to learn and acquire personal life skills to enable them to consider the possibility of moving on to supported living. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ellenborough Court DS0000071852.V372794.R01.S.doc Version 5.2 Page 8 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 Ellenborough Court DS0000071852.V372794.R01.S.doc Version 5.2 Page 9 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): 1, 2, 3, 4 and 5 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. People benefit from sufficient information in an appropriate format to help them make an informed choice of home. They can visit and have a trial period before they decide to stay. They also benefit from an in depth assessment that looks at their personal needs, and a contract in a format that they can understand. EVIDENCE: We asked the manager for a copy of the Statement of Purpose and Service User Guide. These were readily available and contained all the information we would expect to see to help people make an informed choice about where they want to live. The Service User Guide was also available in an Easy Read format for people who may have difficulty understanding the written guide. We looked at the care plans for people living in the home. We saw that they contained very in depth pre admission assessments, which identified people’s personal needs. They also showed that the manager had met with people who wanted to move into the home and discussed their needs and expectations. We also saw care plans from Social Services which may identify needs the service user was not aware of. Ellenborough Court DS0000071852.V372794.R01.S.doc Version 5.2 Page 10 We looked at Contracts that are agreed between the service user and the home. They were also written in Easy Read format so that people could understand what they were agreeing to. Everybody living in the home had a signed contract. People we spoke to said they had been given a trial time when they could ‘test drive’ the home to see whether it was the right placement for them. Two people said that they had been helped to make the decision by their social workers and staff in the home and they had been given enough information. They both said that the move had been the best thing they had done. Ellenborough Court DS0000071852.V372794.R01.S.doc Version 5.2 Page 11 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, 8, 9, 10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People benefit from clear person centred care plans that have been discussed and agreed with them, showing that they are consulted and make decisions about their life. They also benefit from clear risk assessments that enable them to take reasonable risks as part of their independent lifestyle. People know that the information held by the home is secure and confidences are respected. EVIDENCE: We looked at the care plans for people living in the home. They showed that people’s personal preferences were respected and taken into consideration when planning the care that the service provides. All the care plans were person centred and included a very in depth assessment of peoples needs. We saw that the care plans had been agreed with people living in the home and had been signed by them. The care plans showed what needs had been Ellenborough Court DS0000071852.V372794.R01.S.doc Version 5.2 Page 12 identified and how those needs were going to be met with a desired outcome for the service user. They included statements about ‘what I like, what I dislike, what makes me angry.’ Boundaries were agreed and there was a positive behaviour support plan in place with acceptable risks identified and agreed with the person. People spoken to said they knew about their care plans and had agreed with them. One person said they knew about taking risks and felt that the staff helped them especially with things like cooking and making tea and coffee as well as going out in the community. Two people showed us their flats and said that they had decided on everything themselves. Both flats reflected their personal choice and involvement in the running of the home. They said they felt that they were involved in the dayto-day decisions and then excused themselves to help the provider to build a cabinet that had just been delivered. When asked about the storage of information one person said they could lock their own things away and were sure that their records were all safe. Ellenborough Court DS0000071852.V372794.R01.S.doc Version 5.2 Page 13 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): 11, 12, 13, 14, 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. People benefit from appropriate leisure and social skills activities relevant to their assessed needs. They maintain contact with friends, family and the local community. They are supported to be independent and are involved in all areas of daily living in the home. People benefit from a healthy and nutritious diet, which they are involved in planning and preparing. EVIDENCE: Two people spoken to talked about their experiences of living at Ellenborough Court. They felt they had ample opportunity to go out and enjoyed contact with the local community. They were planning to go out for the afternoon with a support worker who was helping them decide where to go. Another person had been out shopping in the morning and was preparing to go out again in the afternoon. All care plans showed a full timetable of planned activities as well as household duties. These showed that people were being Ellenborough Court DS0000071852.V372794.R01.S.doc Version 5.2 Page 14 supported to access leisure and educational interests as well as learning new social skills. One person talked about their arts interest and showed us their art that was displayed on their flat wall, another talked about their interest in cars. Staff felt they helped people to access the community in a personal and individual way supporting their diverse needs and interests. People are supported in their individual flat on a one to one basis. The home does not have communal areas so people prepare their own meals with the support and assistance of a staff member. This provides people with a more natural experience of life, and encourages individualism. People spoken to liked the support they received in planning and preparing their meals. Those who could not prepare their meals were still involved in identifying personal likes and dislikes. Ellenborough Court DS0000071852.V372794.R01.S.doc Version 5.2 Page 15 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. People living in the home benefit from personal and specialist healthcare support that is provided in a person centred way respecting choices and rights. They benefit from and are protected by the homes policies and procedures for the administration of medication. EVIDENCE: Care plans showed that people at Ellenborough Court are supported to access healthcare specialists as well as the Mental Health and Learning Disabilities Teams. Support in the home is gender specific if required and the staff team skill and gender mix reflects this. Included in the care plans was a summary and emergency plan that included the contact details for next of kin and social workers. We saw that there was a clear indication of possible triggers that might show when a person’s mental health was deteriorating and very clear guidance for staff. Ellenborough Court DS0000071852.V372794.R01.S.doc Version 5.2 Page 16 Health Action Plans are in place and people have been supported in attending specific appointments such as dentist, optician or hospital outpatient or screening clinics. Medication is stored in lockable cupboards in each person’s flat if they have been assessed as able to administer their own medication they would be supported to by staff. All records were up to date and correct. Staff confirmed that they would seek advice and support from the local community nursing services or the local hospice to help people handle any issues if they needed nursing or terminal care. Ellenborough Court DS0000071852.V372794.R01.S.doc Version 5.2 Page 17 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. People benefit from and are protected by the complaints and safeguarding procedures in the home. Staff are fully aware of the procedures to follow to protect people from abuse. EVIDENCE: Copies of the homes complaints policy and procedure are included with the Service User Guide these are written in Easy Read format for people to understand fully. People spoken to said they knew how to make a complaint and who to approach. Two people said they felt easy about talking to staff. The service user guide also directs people to an advocacy service led by People First, as well as providing the address and contact details for CSCI and the provider. We saw a copy of the North Somerset policy and procedure for Safeguarding Adults under No Secrets, which is available for all staff to read. Staff spoken to said they knew who to inform if they suspected abuse and they all knew about the homes whistle-blowing policy. Staff records showed that they had all received appropriate training in Safeguarding Adults. Ellenborough Court DS0000071852.V372794.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, 25, 26, 27, 29 and 30 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. People benefit from a homely well-maintained environment that is individual to their personal needs, likes and dislikes. All areas are clean and hygienic. EVIDENCE: Ellenborough Court consists of 5 flats that are personal to the needs, likes and dislikes of the person living in them. We spoke to people about their flats they were personalised and contained the furniture they had chosen and was decorated in a way they had decided on. Each flat reflected the individual likes and dislikes of the person. All the people we spoke liked their flats and two people in particular took great pride in showing us around and explaining that they were responsible for keeping their flats tidy. They especially liked the fact that they had their own kitchens and own personal belongings around them. Ellenborough Court DS0000071852.V372794.R01.S.doc Version 5.2 Page 19 We also saw that when people have higher physical needs that equipment is provided for them to lead as natural a life as possible. There are no communal areas in Ellenborough Court supporting people in living as normal a life as possible. Each flat has its own bathroom facilities so people can maintain personal privacy and dignity within their own living space. People living in the home are responsible for keeping their flat clean and tidy with the support of staff. Household duties are included in their activities timetables and people said they liked looking after their own ‘home.’ Ellenborough Court DS0000071852.V372794.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): 31, 32, 33, 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. People benefit from a staff team who have clear job descriptions, are competent and qualified and trained to meet the diverse needs of people in the home. They are also protected by clear policies and procedures for the recruitment of new staff and supervision of existing staff in the home. EVIDENCE: We looked at the personnel files for staff working at Ellenborough Court. We then spoke to people living in the home and staff working there. Staffing levels are determined by the assessed needs of people living in the home. These can change daily as some people may need two to one support sometimes. The usual ratio is one to one support for all people in the home. We looked at the personnel files and they showed that all staff had a job description, which clearly stated what their roles and responsibilities were to support people in achieving a normal lifestyle whilst improving personal life skills. They also showed that people have been encouraged to attend training specific to the needs of the people living at the home as well as all mandatory Ellenborough Court DS0000071852.V372794.R01.S.doc Version 5.2 Page 21 training. It was evident that people are encouraged to obtain an NVQ qualification, which has resulted in 84 of the staff in the home with an NVQ 2 or 3 In Health and Social Care. We spoke to people living in the home they said they felt very well supported by staff who were ‘nice, kind and knew what they were doing.’ Two people named one support worker that they were very fond of; they also said that it was good that they knew all the staff. We spoke to staff who felt they received all the support and training they needed to carry out their roles in the home. They confirmed that they received regular supervision from management but this was not formally recorded. We recommended that a formal record of staff supervision is kept to show that staff receive the support they need to maintain a consistent level of care. Ellenborough Court DS0000071852.V372794.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, 38, 39, 40, 41, 42 and 43 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People benefit from a home that is well managed in an open and approachable way, which considers peoples personal input into the day to day running of the home. The policies and procedures, record keeping and health and saftey in the home safeguard people living there. EVIDENCE: The responsible individual for Ellenborough Court is Dr Emily Bladon. She is a Consultant Clinical Psychologist chartered with the British Psychological Society. She has a number of years experience working with people with learning disabilities and mental health problems that also have forensic needs. Dr David Wing is the registered manager of Ellenborough Court. He is a Consultant Clinical Psychologist who is chartered with the British Psychological Ellenborough Court DS0000071852.V372794.R01.S.doc Version 5.2 Page 23 Society and has experience of working in the forensic care and treatment of learning disabled offenders. He is also trained as a Registered Nurse for Adults (RNA) and a Registered Nurse for People with Learning Disabilities (RNLD). Dr David Wing intends to hand over the managers post to the Deputy Manager Mr Michael Stuart who has started the registration process with the Commission and will on successful completion be the registered manager for the home. Mr Stuart has in a previous post been the lead Social Worker for the local community Learning Disability Team and has been involved in Safeguarding Adult teams in previous roles. (Since the draft report was written Mr Stuart successfully completed the registration process with the commission and is now the registered manager for Ellenborough Court. This will be reflected in all future documentation.) People we spoke to said they felt they could talk to any member of staff and were observed to have a relaxed and friendly rapport. Staff said they felt well supported and able to approach anybody at any time. It was evident that people living in the home are involved in the day to day running of the home and organising their personal lives. As the home has only been open 6 months a Quality Assurance process with people in the home has not been carried out however a comprehensive programme is in place and planned for the New Year. Progress in this area will be assessed at the next inspection. All the policies and procedures for the smooth running of the home were in place and reviewed and up to date. We looked at records relating to the servicing of equipment used in the home. All the records were up to date and available for inspection, these included the COSHH records, which are the guidelines for staff to follow if they spill, drink or are splashed by chemicals used in the home. 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. Ellenborough Court DS0000071852.V372794.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 4 2 3 3 3 4 3 5 3 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 4 26 4 27 3 28 X 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 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 3 3 3 3 Ellenborough Court DS0000071852.V372794.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 YA36 Good Practice Recommendations A formal record of staff supervision needs to be maintained Ellenborough Court DS0000071852.V372794.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West 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 Ellenborough Court DS0000071852.V372794.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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