Care Home: The Hollies

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What the care home does well The HolliesDS0000072961.V375126.R01.S.docVersion 5.2People get information about the service and it is written in ways that people can understand.People who use the service are listened to when they give their opinions.People who use the service are supported to stay in contact with family and friends.The HolliesDS0000072961.V375126.R01.S.docVersion 5.2Page 8People who use the service are supported to take part in lots of different activities. What has improved since the last inspection? This is The Hollies first inspection. What the care home could do better: The HolliesDS0000072961.V375126.R01.S.docVersion 5.2The manager should make sure that she has supervision with her staff to make sure they are doing their job properly.The manager could also tells us about all the things that happen to people who live in the home instead of just the very serious things. Key inspection report CARE HOME ADULTS 18-65 The Hollies Alfreton Road Sutton In Ashfield Nottingham NG17 1FW Lead Inspector Susan Lewis Key Unannounced Inspection 21st May 2009 09:00 The Hollies DS0000072961.V375126.R01.S.doc Version 5.2 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. The Hollies DS0000072961.V375126.R01.S.doc Version 5.2 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 The Hollies DS0000072961.V375126.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Hollies Address Alfreton Road Sutton In Ashfield Nottingham NG17 1FW 01623512850 01623512850 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) Quality Care (EM) Ltd Mrs Edwina Charlotte Davies Care Home 18 Category(ies) of Learning disability (18) registration, with number of places The Hollies DS0000072961.V375126.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 - CodePC to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning Disability - Code LD The maximum number of service users who can be accommodated is: 18 Date of last inspection Brief Description of the Service: The Hollies is a purpose built service with the accommodation split over four bungalows. The home is registered to accept 18 people with learning disabilities several of whom may have behaviour that challenge. Each bungalow has ramped access making it suitable for people with physical needs. Bedrooms and communal areas are furnished in a domestic manner and people who come to live in the home are encouraged to personalise their bedroom. Each bungalow has its own transport; however the service is close to public transport and local amenities. There is parking on site; access to the site is through locked gates which are operated by a speaker phone. Information about the service can be found in the service user guide and the statement of purpose which are to be found in the main office building. The weekly fees range from £1850 to £7600 depending on the assessed needs. The Hollies DS0000072961.V375126.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 two star – good service. This means the people who use this service experience good quality outcomes. We visited the home in May 2009 and met with the manager, staff and people who use the service. The visit started at 9:00 am and lasted for five hours We asked the manager and the staff what they do for people. We asked them how they learnt about this. As part of our inspection, we also sent out surveys to some people who live at the service, members of staff who work in the home and family members. We received four replies from people who live there, three responses from members of staff and five from families. They gave us positive responses to our questions. The Hollies DS0000072961.V375126.R01.S.doc Version 5.2 Page 6 We looked at people’s records to see if the support they received was actually what they wanted. We also talked to staff and to families to check this out. We looked at staff files to see if they were safe to work with people. We looked at other paperwork, like any complaints people have made. We found it difficult to speak to some people who use the service so we spoke to some family members as well. What the service does well: The Hollies DS0000072961.V375126.R01.S.doc Version 5.2 Page 7 People get information about the service and it is written in ways that people can understand. People who use the service are listened to when they give their opinions. People who use the service are supported to stay in contact with family and friends. The Hollies DS0000072961.V375126.R01.S.doc Version 5.2 Page 8 People who use the service are supported to take part in lots of different activities. What has improved since the last inspection? What they could do better: The Hollies DS0000072961.V375126.R01.S.doc Version 5.2 Page 9 The manager should make sure that she has supervision with her staff to make sure they are doing their job properly. The manager could also tells us about all the things that happen to people who live in the home instead of just the very serious things. 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. The Hollies DS0000072961.V375126.R01.S.doc Version 5.2 Page 10 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Hollies DS0000072961.V375126.R01.S.doc Version 5.2 Page 11 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): People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who move to the home are assured that their needs can be met. EVIDENCE: The Hollies is a new service and this is its first inspection since it was registered in October 2008. We looked at the home’s Statement of Purpose and Service User Guide – these are documents, which all care services must have. They tell people who might want to move in about the home and what they can expect if they live there. We found they had useful information to tell people about what kind of service the home offers. The Service User Guide is written in plain English with pictures, which can help people to understand it. We saw evidence in care plans that extensive assessments were carried out on people prior to them moving to the service. These assessments included information gathered from relatives and professionals who know the person. Staff spoken with told us that the manager visits the person before they decide to move to the home to make sure that the staff are able to meet the person’s needs. The Hollies DS0000072961.V375126.R01.S.doc Version 5.2 Page 12 The staff told us that people are able to visit the service and spend time getting to know it before making a decision to move in. Visiting families also told us that their relatives had been able to look around the home before they made any decision to move. The pre inspection information told us that the staff encourage what they call a ‘period of transition’ to help people settle when moving to the service. The Hollies DS0000072961.V375126.R01.S.doc Version 5.2 Page 13 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): People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported to take risks and decisions about their lives with the support they need. EVIDENCE: We looked at people’s plans of care to see if they are personalised and reflect peoples preferences to make sure that they are supported in their preferred way. Plans of care are in place and contain detailed information in regard to peoples identified needs to make sure that they are supported appropriately and their needs are met. Staff told us how they consult with people about the care and support that they may need and plans of care are drawn up in unison with people using the The Hollies DS0000072961.V375126.R01.S.doc Version 5.2 Page 14 service so that they feel that their rights and choices are maintained. Staff told us that they used various methods to ensure that people could take part in creating their care plan such as picture as well as spending time getting to know the person and understanding their method of communication. We saw that staff recognise peoples skills and independence so that these may be maintained and enhanced. We saw this in how plans of care were developed to support people to prepare snacks and carry out other domestic tasks in their bungalows. Appropriate risk assessments and management plans are in place for peoples identified risks to make sure they remain safe. We saw that these are discussed and negotiated with people so that their rights and choices are fully recognised and people are supported to take risks as part of an independent lifestyle. Staff spoken with are able to discuss in detail the needs of people living at the service and how they support them to meet their needs. They told us, I am involved in writing care the manager writes the main part and we develop it with the person as we get to know them better’. We sent out surveys to people who use the service before we did the inspection and they told us that they receive the care and support they need. The Hollies DS0000072961.V375126.R01.S.doc Version 5.2 Page 15 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: People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are able to enjoy a full and stimulating lifestyle with a variety of options to choose from. The routines, activities and plans are person centred, individualised and reflect diverse needs. EVIDENCE: Staff spoken with said that they respect peoples rights and they discussed how they ensure that people are supported appropriately so that these are maintained. Staff were able to demonstrate how they supported people to have their own space and ‘respecting that their room is private. People who use the service told us that staff listen to them and act on what they say. We found that all residents have family who come to see them or who they meet up with. The manager and care staff are supportive in enabling residents The Hollies DS0000072961.V375126.R01.S.doc Version 5.2 Page 16 to see relatives when they want. Visiting families we spoke with confirmed this. People using the service are supported to live an independent and flexible life; some go out to do voluntary work where as others go out visiting local community resources such as the swimming pool or cinema. Plans of care showed that staff discussed with families about arranging holidays and day trips. There are photographs displayed in each bungalow which show that people are involved in social activities. Each bungalow also has their own vehicle this is used to transport people when they go out on activities. Staff spoken with told us that the service is well run and there are enough activities for people to do. People who use the service also told us this. On the day of the visit some people using the service were at home. We saw people spend time in their bungalows with staff playing different games, using the trampoline or listening to music. Staff spoke of supporting people when they go on out on activities also ensuring that as they become aware of peoples individual needs and characteristics they modify activities so that they get the most enjoyment out of as life possible. An example of this was when a person became anxious and distressed when going to the large supermarket. Staff now go to a smaller supermarket, which is less busy. This means the person can still go shopping and have a full and active life. Staff were heard talking to people in a pleasant friendly manner. Interaction between people using the service and staff is positive and we saw that staff are respectful at all times. Menus are created taking into consideration people’s likes and dislikes as well as healthy and nutritional meals. People also eat out within the community during the week at various local venues. Where people have special dietary needs these are catered for. Staff spoken with showed a good understanding of supporting people with specialist needs. People who use the service told us that they always like the meals. The Hollies DS0000072961.V375126.R01.S.doc Version 5.2 Page 17 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): People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive effective personal and healthcare support using a person centred approach with support provided based upon the rights of dignity, equality, fairness, autonomy and respect EVIDENCE: Care plans examined contain information in regard to peoples personal, emotional and health care needs. There is detailed information about peoples preferences and the support that they require. Families spoken with confirmed that their relatives receive the support they need. We saw within plans of care that people are supported to access specialist services such as the doctor, optician and speech and language therapists, making sure that their health and well being is maintained. People who use the service told us staff always make sure they see a doctor if they are not well. The Hollies DS0000072961.V375126.R01.S.doc Version 5.2 Page 18 We checked how staff look after and give out medication. Medicines are kept securely locked away, and staff keep proper records to show what medication is being given to each person. Staff have a good understanding of what each person needs and why they need it. All members of staff have had training about how to give out medication safely. The Hollies DS0000072961.V375126.R01.S.doc Version 5.2 Page 19 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): 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 who use the service are protected by a complaints procedure and there is a clear system for staff to report issues of poor practice to management. EVIDENCE: We saw that there is a complaints procedure in the home, which is written in plain language, with diagrams to help understanding. The residents who currently live in the home would not be able to complain independently, and staff spoken with told us how they would handle a complaint if received to make sure that this is dealt with and resolved. One member of staff told us: “We have a complaints procedure in place… I would pass this information on to the manager.” The service has received two complaints since October 2008 when the service first opened. All complaints are logged and outcomes recorded. A family visiting on the day of the inspection who had made a complaint said they were very satisfied with how their concerns had been dealt with and felt the manager had responded quickly and gave them a satisfactory answer. They said “We have no worries about our relative being here; when we go home after a visit we feel they are safe and well cared for”. The service has policies and procedures for responding to suspicion or evidence of abuse, or neglect, in place to protect people who use the service. Care staff The Hollies DS0000072961.V375126.R01.S.doc Version 5.2 Page 20 have had training to help them to understand how to safeguard people who live in the service and protect them from harm. Staff spoken with were able to demonstrate an understanding of their responsibility to alert the manager of any disclosure or suspicion of abuse. A staff member was able to give an example of when poor practice was reported to the manager and how the manager responded to ensure the safety of the people who use the service. The manager had sent us a report of an incident that we said should have been reported as a safe guarding issue. The manager arranged for this to be done as soon as it was brought to her attention. This ensures that where people who use the service could potentially be abused are reported and investigated to minimise any concerns or risk. Where people need support with their finances and budgeting this is referenced in a plan of care. The Hollies DS0000072961.V375126.R01.S.doc Version 5.2 Page 21 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): People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The provider and manager have ensured that the physical environment of the home provides for the individual requirements of the people who use the service who live there. EVIDENCE: The home is purpose built and split into 4 bungalows, each bungalow has between two or four people living there. They also have their own laundry and kitchen facilities that support the people who live there to live as independently as possible. There is also a central laundry for heavily soiled items to maintain infection control in each unit. These well built bungalows are furnished and decorated to a high standard, we saw that people who live there are able to personalise their bedrooms. Where people have specialist needs these are taken into consideration when the The Hollies DS0000072961.V375126.R01.S.doc Version 5.2 Page 22 management thought about decorating the service. Some lounges do not have curtains on poles that may be pulled down, rather they have fitted them using alternative methods. Where necessary some people do not have glass in their bedroom windows but special Perspex, again to maintain the person’s safety. As the living accommodation is all on one level this service is suitable for people with mobility needs. The Hollies DS0000072961.V375126.R01.S.doc Version 5.2 Page 23 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): 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 who use the service are protected by the recruitment practice and benefit from being supported by well trained staff. EVIDENCE: The home is staffed according to the assessed needs of each person who uses the service. Staffing therefore can vary from someone needing three staff to support them during the day to only needing two staff to support them during the night. We saw that needs dictated how many staff were on duty at any one time and rotas reflected this. Staff files looked at show us that all the documentation required by law is in place to make sure that people are protected from unsuitable people being employed. Staff spoken with confirm that they underwent a Criminal Record Bureau check (a police check to see if a person has a criminal record or police caution) prior to commencing employment at the care home. The Hollies DS0000072961.V375126.R01.S.doc Version 5.2 Page 24 The manager told us that they encourage people who live at the service to be involved in recruitment depending on their abilities. Staff spoken with confirmed this. Staff are encouraged to undertake National Vocational Qualification training (a nationally recognised work and theory based qualification designed to enhance peoples knowledge and skills in caring for people) and training records confirmed this, over 50 of staff have this qualification. So that staff are aware of their job roles and responsibilities when commencing employment they undertake an induction. There is evidence of staff undertaking this within staff files examined and one member of staff confirmed that they had undertaken an induction when they first started working at the care home. To ensure that staff have the necessary skills and knowledge to meet peoples needs they undertake a wide range of training. Staff training files examined show evidence of training in a number of health and safety subjects, medication administration and specialist courses in working with people with Epilepsy and Autism. To ensure that where people need to be protected from harming themselves or other people around them staff have undertaken specialist training in non violent crisis intervention training and are in the process of undertaking further training to manage behaviour that challenges. Staff spoken with are able to discuss how peoples needs affect them and the support that they require. They stated that the level of training that they receive is good, “The home provides good training for staff to help them perform well in their roles”. We spoke with staff to check if they were receiving supervision from the manager to check if they were doing their job well. Staff said that as the home only opened in October 2008 the manager has yet to start a supervision programme for the deputy or bungalow managers. However the bungalow managers have started supervising the care staff. The manager is aware this is an area that needs to be completed. The Hollies DS0000072961.V375126.R01.S.doc Version 5.2 Page 25 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): 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 run in the best interests of the people who live there. EVIDENCE: The registered manager was present throughout the inspection and demonstrated excellent management knowledge. She ensures that she remains up to date with all mandatory training and she has completed the Registered Managers Award (a nationally recognised work and theory based qualification designed to enhance management skills). The manager is registered with us as being a fit person to manage a care service. The Hollies DS0000072961.V375126.R01.S.doc Version 5.2 Page 26 Staff spoken with state that the management team are very supportive and approachable, “the manager is very approachable, if there are ever any issues we can always discuss these with her.” Records are stored securely and comply with the Data Protection Act 1998 they are correct and kept up to date. The manager is in the process of developing a quality monitoring system and evidence was seen in minutes of meetings held that a system is being set up. The provider of the service carries out visits under his legal duty as owner to ensure the service is operating correctly and people who live there are happy. Staff meetings are held regularly and staff told us that people who use the service are able to talk to them about any problems they may have about the service. The manager tells us abut some incidents that happen in the service so we know what is going on. However in checking the incident records for people who use the service it was clear that the manager does not tells us about everything. We discussed this with the manager who told us this was because due to the complex needs of some people who live at the service there are a lot of things happening. A sample of records relating to health and safety were examined. Records relating to electrical and gas testing were looked at and had been carried out at the intervals required by law. Pre inspection information also confirmed that all health and safety tests are carried out regularly. The Hollies DS0000072961.V375126.R01.S.doc Version 5.2 Page 27 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 4 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 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 X 33 X 34 4 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 4 X 4 X 3 X X 4 X Version 5.2 Page 28 The Hollies DS0000072961.V375126.R01.S.doc 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 2 Refer to Standard YA22 YA42 Good Practice Recommendations The manager should ensure that incidents that have a safe guarding element are routinely reported to the local authority for them to investigate. Due to complexity and number of incidents that happen in the service the manager could send monthly returns regarding the general day to day incidents that occur as well as any reports of a more serious nature. The Hollies DS0000072961.V375126.R01.S.doc Version 5.2 Page 29 Care Quality Commission East Midlands Region Citygate Gallowgate Tyne and Wear NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.eastmidlands@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). 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. 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