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ERS-01-250
STATEMENT OF PURPOSE KEY CONTACTS:
REGISTERED MANAGER
Diana Tuhumwire
BUSINESS, COMPLIANCE & QUALITY
ASSURANCE MANAGER
MNISI, Khulekani Praisegod
MANAGING DIRECTOR
MNISI, Lettie Nomsa
HEAD OFFICE ADDRESS
Office 3.9 Laurie House
Colyear Street
Derby,
DE1 1LA
Tel: 01332 895984
Mobile: 07746 117 191/ 075 175 15556
Email: [email protected]
COMPANY REGISTRATIONS
Company Reg No. 10045790
CQC Reg No. 1-4259704280
Location ID. 1-4297405090
VERSION 1.0
DATE : 20TH JUNE 2017
DOCUMENT/SOP/ERS-01-250 VERSION 1.5 / AUG 2017 REVIEW DATE: AUG 2018
pg. 2
2
CONTENTS CHANGE MANAGEMENT 3
INTRODUCTION 4
AIMS AND OBJECTIVES 6
STATUS AND CONSTITUTION 7
ORGANISATION & MANAGEMENT STRUCTURE 8
OUR STAFF 9
SERVICES WE PROVIDE 10
WHAT WE WON’T DO 11
RECRUITING AND ASSESSING STAFF 12
TRAINING AND SUPPORT 13
OUR REGISTERED MANAGER 18
QUALITY ASSURANCE 19
FACTS AND FIGURES 22
BUSINESS INSURANCES 22
USEFUL CONTACTS 23
COMPLAINT RECORD FORM 26
DOCUMENT/SOP/ERS-01-250 VERSION 1.5 / AUG 2017 REVIEW DATE: AUG 2018
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3
CHANGE MANAGEMENT
Date of
Produced:
17th June 2017
Version Number: 1.0
Document
Control Number:
ERS-01-250
Reason (s) for
Review
First Issue
Where the
changes
necessary?
N/A
Summary
Development of Statement of Purpose is in line with current
Fundamental Standards and is a requirements of CQC Care
Quality Commission (Registration) Regulation 2009, Regulation 12(3)
Relevant
Legislation
1. The Health and Social Care Act 2008 (Regulated Activities)
Regulations 2014
2. The Health and Social Care Act 2008 (Regulated Activities)
(Amendment) Regulations 2015
Underpinning
Knowledge -
What have we
used to ensure
that the policy is
current
1. Care Quality Commission, (2016), Provider Handbooks.
[Online] Available from:
http://www.cqc.org.uk/content/provider-handbooks
2. CQC, (2016), Regulations and guidance. [Online] Available
from: http://www.cqc.org.uk/content/regulations-service-
providers-and-managers
Suggested action: 1. Submit to CQC
DOCUMENT/SOP/ERS-01-250 VERSION 1.5 / AUG 2017 REVIEW DATE: AUG 2018
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1. Introduction
This document outlines the way ERS operates as a Domiciliary Care Service
for adults in England and Wales. Our Statement of purpose is being
produced in fulfilment of the Health and Social Care Act 2008 requirement.
This statement is reviewed annually and updated as necessary.
Where necessary ERS will provide the information included in this statement of
purpose to all customers in a format appropriate to their needs which may
include large print, Braille, or in an audio or electronic format.
Our services are available on a 24-hour basis throughout the year. We have a
separate out-of-hours service with an on-call person to support staff, service
users and our clients outside normal working hours.
1.1. ERS STATEMENT OF PURPOSE IS AVAILABLE TO
• ERS employees;
• Families and relatives of our clients and of prospective clients;
• Adults in receipt of our services;
• Local Authorities and Health and Social Care Trusts;
• Clinical Commissioning Groups;
• Colleagues from other social care agencies;
• Regulatory Bodies – Care Quality Commission and
• The public
1.2. OUR STATEMENT OF PURPOSE HAS BEEN DEVELOPED TO
MEET THE REQUIREMENTS ARISING FROM
• Health and Social Care Act 2008 (Regulated Activities)
Regulations 2014
• Care Quality Commission (Registration) Regulations 2009
DOCUMENT/SOP/ERS-01-250 VERSION 1.5 / AUG 2017 REVIEW DATE: AUG 2018
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2. AIMS AND OBJECTIVES
2.1. Our Mission:
To provide a compassionately caring, safe, effective, responsive
and well-led service to those in our care.
2.2. Our Aim:
To provide unequalled personalised compassionate care and support to
people who are unable to look after themselves in their own homes.
To do this, we work to understand the benefits of living independently in
one’s home and the positive effects this has on a person’s quality of life.
We work collaboratively with multi-disciplinary teams and in partnership
with local authorities/health and social care trusts and the community to
offer the best support to our service users which is designed to help them
achieve their individual needs.
2.3. Our objectives:
To commit to:
• a person-centred and inclusive partnership based approach to our
service delivery, which embraces every individual in receipt of our
service, their family/carer, local authority/health and social care
trusts and other agency colleagues.
• every individual in our service in order that they should have a
stable fulfilling environment that enables them to retain their
independence and remain in control of choices and decisions
• every individual’s rights in order that they continue to have
Independence, Sense of Security, feel that their dignity is respected,
DOCUMENT/SOP/ERS-01-250 VERSION 1.5 / AUG 2017 REVIEW DATE: AUG 2018
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feel empowered through acknowledging their Civil Rights and
uphold principles of Confidentiality.
• Promoting an all-inclusive culture and spirit which transcends racial,
cultural, religious, sexuality and social background of every
individual in our care;
• Recruitment of the best appropriately qualified staff who will reflect
our multicultural society, train, support, develop and empower them
to deliver an unequalled service to every individual in our service.
• Providing a seamless 24-hour service to every individual person in
our service 365 days a year.
3. STATUS AND CONSTITUTION
ERS an independent domiciliary care organisation for adults in need of social
care, is a private limited company incorporated in England and Wales on 7th
March 2016 under the Companies Act 2006. The Company Number is
10045790.
In accordance with accordance with the Companies’ Acts 2006, we
produce a Memorandum and Articles of Association, copies of which are
available to the government commissions, which regulate services for adults
in social care throughout the United Kingdom.
DOCUMENT/SOP/ERS-01-250 VERSION 1.5 / AUG 2017 REVIEW DATE: AUG 2018
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3.1. ERS ORGANISATION STRUCTURE
REGISTERED
MANAGER Diana Tuhumwire
COMPLIANCE &
QUALITY ASSURANCE
MNISI, KHULEKANI PRAISEGOD
BUSINESS MANAGER MNISI, LETTIE NOMSA
ADMIN & FINANCE MNISI, KHULEKANI PRAISEGOD
SERVICE
COORDINATOR MNISI, KHULEKANI PRAISEGOD
CARE COORDINATOR
X
1
HOME CARE- CARE
WORKERS
X
15
RESPITE CARE –
CARE WORKERS
X
10
LIVE-IN CARE –
CARE WORKERS
X
15
DOCUMENT/SOP/ERS-01-250 VERSION 1.5 / AUG 2017 REVIEW DATE: AUG 2018
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4. MANAGEMENT STRUCTURE
The ERS Managing Director is accountable and responsible for the strategic
direction, service development, compliance, quality assurance and
performance of the organisation.
The Managing Director is supported by a dedicated Management Team which
meets weekly to direct and monitor operational and financial performance of
the company’s activities, business planning and policy development. The
management team is supported by a qualified, trained, competent and
dedicated team of staff, comprised of office administrators and field care
personnel.
4.1. OUR STAFF:
Our recruitment process ensures that we have an excellent team of highly skilled
professional care staff at your service, each of which have undergone
continuous training to ensure the highest quality of services are provided. This
training includes induction into ERS Behavioural Framework and Care Certificate.
The induction training also includes an orientation into roles and organisation of
ERS.
Training needs and opportunities for further development are identified through
Training Needs Analysis and supervision sessions. To ensure services are
consistently of a high quality, annual appraisal for all staff and Care/Support
Workers are carried out to identify, individual and team performances in line with
outcomes of service users.
All registered managers will be qualified health and social care professionals
who have extensive management experience in private, public and voluntary
sectors.
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In the events of having to engage with other professionals and individuals we will
carry out extensive verification of their credentials and qualifications. All relevant
checks for our staff are performed to ensure that welfare of those in our care is
safeguarded.
Everyone working for ERS is covered either by their appropriate professional
indemnity and public liability insurance.
DOCUMENT/SOP/ERS-01-250 VERSION 1.5 / AUG 2017 REVIEW DATE: AUG 2018
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5. OUR SERVICES
We are a re-ablement service through our domiciliary, respite and live-in
services which we provide to young adults, 18 years and 65 years of age, and
adults over 65 years of age including: -
a. Adults with Learning Disabilities
b. Adults with sensory loss including dual impairment
c. Adults with mental health problems
d. Adults with Autistic spectrum disorders including Asperger’s Syndrome
e. Adults with acquired brain damage
f. Older people in their homes requiring support with their needs
g. Those requiring palliative care
5.1. Domiciliary Services
ERS domiciliary care service supplies a well resourced and dedicated care
staff on a floating and outreach basis to young adults and adults in the
community living at home or in their own home, adults aged up to 65 years
and over. This capable and motivated team will provide services which may
include:
5.1.1. Personal care
• Assisting service users with getting up and going to bed
• Assisting with washing, bathing, showering and maintaining good
personal hygiene and dressing
• Transferring from bed to chair/wheelchair/toilet with or without hoists
• Shaving
• Hair care
• Nail care
• Changing of incontinence pads
• Emptying catheter bags
• Colostomy bag care
5.1.2. Housework
• Hoovering
• Ironing
• Changing beds
• Dusting and cleaning
• Washing up
5.1.3. Money and Shopping
• Shopping
DOCUMENT/SOP/ERS-01-250 VERSION 1.5 / AUG 2017 REVIEW DATE: AUG 2018
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• Assisting with shopping list, etc
• Paying bills
• Cashing benefit entitlement
5.1.4. Escorts to and from:
• Shopping
• Hospital and medical appointments
• Day centres/ Play schemes etc - please note that this only includes the
use of the service users own care or walking/wheelchair assistance
5.2. Respite Services
Our respite service provides companionship to those individuals living alone,
or short respite care (a couple of hours) to enable informal carers to go out
for a break. ERS offers individually tailored planned activities both within the
community and in-house, having regard to the age and interests of the
service user.
5.3. Live-in Services
We also provide a Live-in service where we supply our dedicated,
compassionate and professional staff to live-in with individuals who may
need round the clock care and support within the comforts of their own
homes.
6. WHAT WE WON’T DO:
The scope of our services excludes work undertaken by skilled and expert of
clinical professionals such as:
• Toe nail cutting
• Ear syringing
• Removing or replacing urinary catheters
• Bowel evacuations
• Bladder washouts
• Injections – involving assembling syringes, administering
intravenously, controlled drugs
• Filling of oxygen cylinders
• Lifting from the floor unaided or baring the weight of a service user
• Tracheotomy care – changing tubes
DOCUMENT/SOP/ERS-01-250 VERSION 1.5 / AUG 2017 REVIEW DATE: AUG 2018
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• Skin prick tests for diabetics
• Any invasive procedures
• Any nursing care services
7. OVERVIEW OF OUR SERVICE
DELIVERY PROCESS ERS has in place a comprehensive process flowchart which maps out the full
range of activities in sequence to how we deliver our services. This may be
triggered by a referral or inquiry telephone call from a private individual or
from social services, we will arrange a convenient time to attend to assess the
service user’s individual needs. This initial assessment places the service user
at the centre of the process.
ERS will also establish to ensure that any specialist needs such as
communication the service user may have will be provided to facilitate a
robust assessment and process of care planning. The assessment is an
opportunity for the service user to discuss preferences, wishes and individual
needs.
Once the care needs have been identified, a care plan will be agreed with
the service user and/or their representative, and a copy of which will remain
in the service user’s home.
In addition, a comprehensive risk assessment will be undertaken to ensure
minimum risk to the service user and the carer. This will include the use of
electricity, equipment, lighting, security, tasks to be carried out and the local
environment. The risk assessment process will also focus on other areas of
vulnerability such as managing money and personal care.
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As part of our quality assurance, the care plan will be regularly reviewed and
updated to ensure that it continues to meet the service user’s ever-changing
needs. Any changes to the care plan will be discussed and agreed with the
service user and their representatives.
8. RECRUITING AND ASSESSING
OUR
WORKFORCE
ERS prides itself in having a robust recruiting policy and procedures which
include thorough assessments of all personnel joining the organisation. Our
approach is fair and objective. We ensure that our advertisements are
accessible to every member of our wider community.
Our recruitment is comprised of six parts namely:
• Application
• Assessment and Interviewing
• Identity/credentials verification/checks,
• Disclosure and Barring Service checks
• References (personal and professional/employment)
• Confirmation of offer
Applicants are required to identify at least one personal referee who will
provide a written testimonial. In addition candidates will be asked to provide
at least one professional/employment referee to whom we will require written
references on company headed papers with full contact details (and those
of their line manager in case they are not head of services). We may contact
referees by telephone upon receipt of written testimonials.
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8.1. Qualifications, Training, supervision, appraisal and
Workforce development:
ERS has robust policies and procedures dedicated to supporting our workforce,
these procedures are reflective of the statutes law, regulations and national
minimum standards and good practice and applicable guidance.
We place prime importance on employing staff that are fit for the job, have
appropriate qualifications, skills and experience to ensure the health and welfare
needs of service users are met. ERS also ensures that all staff are properly trained,
and have adequate supervision and regular appraisal. We endeavour to ensure
that service users have confidence in their staff members and that their service
can be relied upon to provide the best quality of care.
ERS’s Registered Manager, Diana Tuhumwire is an appropriately health and
social care professional with over 10 years’ experience in the sector. Her
experience comes from working in various roles in children and adult services.
She also has experience working with people with mental health problems and
the elderly.
Diana has extensive experience in the commercial sector where she worked in
capacities of recruitment consultant, administration and customer care.
8.1.1. Diana Tuhumwire’s qualifications include:
• Master of Art Public health;
• Pg. Dip in Management;
• BA Economics
8.1.2. Diana Tuhumwire’s current studies:
• National Care Certificate
8.1.3. Diana Tuhumwire’s future studies:
DOCUMENT/SOP/ERS-01-250 VERSION 1.5 / AUG 2017 REVIEW DATE: AUG 2018
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• Level 5 Leadership and Management in Health and Social
Care
8.1.4. She has also done the following training:
• Manual Handling
• Emergency First Aid
• Infection Control
• Safeguarding children and adults
• Health & Safety
• Data protection
• Epilepsy
• Dementia
• Duty of care
Diana believes that leading by example means that he should have auditable
history both socially and professionally to demonstrate character, honesty,
reliability, integrity and fitness to represent ERS.
Her qualifications, records of achievements, DBS and references are kept within
personnel files at our head office. These records are readily accessible for
inspection whenever required.
8.1.5. Mandatory Care Certificate:
ERS provides training resources and support to ensure that all its staff members
must attain the mandatory Care Certificate within 12 weeks of starting their new
role within our organisation. The Care Certificate covers the following 15
Standards:
Understanding your role: Personal development: Duty of care: Equality and
diversity:
Work in a person-centred way: Communication; Compassion, dignity and
privacy:
Hydration and nutrition: Dementia and cognitive issues: Safeguarding of
adults and children:
DOCUMENT/SOP/ERS-01-250 VERSION 1.5 / AUG 2017 REVIEW DATE: AUG 2018
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Basic life support: Health and safety: Handling information: Infection control
and prevention.
Regular updating of training takes place, together with specialist training on
particular topics or types of client e.g. food hygiene or those service users
suffering from Alzheimer's disease.
Additionally, over a 2-year period, staff, receive training to NVQ II/III standard or
equivalent
8.1.6. ERS Behavioural Framework
ERS.’s Behaviours Framework forms part of the overall strategy for achieving our
Vision, Purpose and Values. The Framework aims to enhance both individual
and organisational performance; it is an integral part of day to day work,
recruitment, induction, learning and development and performance appraisal.
The Framework defines the effective core behaviours that all staff are expected
to demonstrate regardless of their specific role.
The Framework outlines the observable and measurable behaviours, attributes
or qualities that we all display when we approach our work. The behaviour
statements provide examples of how we need to perform our roles, rather
than what we need to deliver. The skills and knowledge required for each job
role are set out in individual job descriptions and regular individual staff
reviews are held to further define job roles alongside job practice.
Having a common understanding of expected behaviours enables the way we
do our job to be assessed and provides clarity when identifying how we can
develop ourselves further in order to achieve our full potential and to continue
to deliver quality services for our valued customers.
Every member of staff is inducted to our ways of working and ethos before fully
joining the main stream workforce in their respective disciplines.
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8.1.7. Monthly Supervision:
All employees are required and entitled to a monthly supervision which is
conducted by their line managers. Once a year every member of our workforce
has a half year appraisal followed by an end of year full appraisal by their line
managers.
In addition to the Mandatory Care Certificates, staff will receive any other
necessary developmental training or support identified within supervision and
appraisals to further build upon the skill sets of our employees.
The Managing Director is responsible for supervision and appraisal of the senior
management team. All line operational managers will have an additional and
brief ‘grandpa’ appraisal conducted by the Managing Director.
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9. OUR REGISTERED MANAGER
Diana Tuhumwire is the Registered Manager for ERS. She will be accountable
for the day-to-day management of the regulated activities of the
organisation.
Her contact address is:
Etiquette Recruitment & Staffing Ltd
HEAD OFFICE ADDRESS
Office 3
9 Laurie House
Colyear Street
Derby,
DE1 1LA
Tel: 01332 895984
Mobile: 07746117191
Email: [email protected]
9.1. The Nominated Person
Diana Tuhumwire is also the Nominated Person of ERS responsible for
supervising the regulated activities of the organisation.
Her contact address is:
Etiquette Recruitment & Staffing Ltd
HEAD OFFICE ADDRESS
Office 3
9 Laurie House
Colyear Street
Derby,
DE1 1LA
Tel: 01332 895984
Mobile: 07746117191
DOCUMENT/SOP/ERS-01-250 VERSION 1.5 / AUG 2017 REVIEW DATE: AUG 2018
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Email: [email protected]
10. QUALITY ASSURANCE
10.1. Continuous Service Improvement
The service is audited and evaluated against the Health & Social Care Act 2008
(Regulated Activities) Regulations 2010 and associated outcomes by the Care
Quality Commission. ERS is also required to keep the regulator informed of the
services it is providing.
Our quality management system is designed along ISO9001 standards. We will
be seeking certification in due course which will also require us to comply with
relevant regulatory and statutory framework in order to maintain the
accreditation.
Monitoring visits to service users are arranged by ERS on a regular basis to ensure
the organisation continues to provide caring, safe, effective, responsive and
well-led care and support that both meets service users’ needs and protects
their rights. ERS will identify and manage risks to both service users’ and staff and
will seek professional safety advice when required.
All service users and their carers are asked to complete an annual user
satisfaction survey which together with advisory reports and information from the
Care Quality Commission will be taken into account in order to promote
continual service improvement.
Independent monitoring of care quality is carried out separately by relevant
commissioning authorities with whom ERS is contracted to provide certain
services for service users.
10.2. Quality Policy and procedures
ERS has a robust Quality Management System which is developed based on
8 fundamental principles are:
10.2.1. Customer Focus: ERS was formed on the premise of understanding
who our customers (service users) are and being able to identify
their needs. This was crucially followed by identifying, establishing
DOCUMENT/SOP/ERS-01-250 VERSION 1.5 / AUG 2017 REVIEW DATE: AUG 2018
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and implementing robust processes focused and geared towards
satisfying our customer (service users) needs and exceeding their
expectations at all times.
10.2.2. Leadership: ERS Managing Director is committed to establishing
unity of purpose, direction and good working environment within
the organisation. Through this leadership, ERS enjoys an environment
in which all staff and employees are involved in achieving the
organisational goals, strategies as well as objectives.
10.2.3. Involvement of people: ERS is fully aware of the importance of
valuing the workforce. Each team member is able to recognise that
only when all staff are fully involved, engaged and motivated that
we are able to achieve maximum benefit and outcomes.
10.2.4. The Process Approach: The organisation has identified through its
core processes, (Process Flow Chart) competent management and
staff are carefully deployed to ensure that we deliver our services
efficiently through effectively managing organisational resources
and work practices, protocols and business activities.
10.2.5. System Approach to Management: As an organisation, we have
done well in identifying, understanding and managing our
interrelated processes to improve and upscale the effectiveness
and efficiency of ERS. This approach enables us to determine the
needs and expectations of our customers. Through this we have
established a robust Quality Policy, as well as Quality goals and
Objectives to ensure that we have an effective process to achieve,
measure and report results.
10.2.6. Continual Improvement: We always aim to be pace setters and
unrivalled in delivering our services. As such we know that there is
always room for improvement. The organisation believes that
improvement is not just about correcting when there is failure, but
also recognising the importance of customer feedback at all stages
of service delivery. From this a full learning curve and process is
DOCUMENT/SOP/ERS-01-250 VERSION 1.5 / AUG 2017 REVIEW DATE: AUG 2018
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21
developed in which practice is constantly reviewed and altered to
meet the highest standards of service delivery
10.2.7. Factual Approach to Decision Making: We have well established
and organised processes managed by competent staff. These
procedures result in accurate collection of data which we then
analyse appropriately to aid logical decision making. This means
that our practice is informed by facts-based decisions.
10.2.8. Mutually Beneficial Relationships: Through meeting our customer
needs and exceeding their expectations, we are aware that the
benefits of building mutually beneficial relationships are wide and
diverse. Achieving every service user’s outcomes means elimination
or minimisation of safeguarding incidences for e.g. the
commissioning Local Authority. This in turn enhances value creation
for customers and helps adopt further partner relationships.
11. REPRESENTATION AND COMPLAINT
PROCEDURE
ERS takes complaints very seriously. Our Complaints Policy and Procedures
ensures that our service users are aware of their right to complain and ensures
that all complaints are dealt with quickly, effectively and appropriately. The
whole process is backed by a series of standardised documentation in line with
our document control procedures.
A summary of complaints outcomes and impact upon service design and
delivery are collated by the Business Manager who is also responsible for
Compliance and Quality Assurance. The report is then tabled as a fixed agenda
item at the monthly Executive meeting. Any necessary actions identified from
these meetings are passed on to respective teams via memos, action plans, staff
meetings, review and supervisions.
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12. FACTS AND FIGURES 12.1. PROJECTIONS
Direct Purchases Contracts:
• First Year target 500 hrs/Week
Local Authorities Contracts:
• First Year target 2500 hrs/Week
Clinical Commissioning Groups Contracts:
• First Year target 2500 hrs/week
Live-In Contracts:
• First Year target 5 Service Users
13. RISK MANAGEMENT 13.1. INSURANCES
Type Level of Cover
Employer’s Liability £10m
Public Liability £10m
Professional Indemnity £5m
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14. USEFUL CONTACTS Etiquette Recruitment & Staffing Ltd
HEAD OFFICE ADDRESS
Office 3
9 Laurie House
Colyear Street
Derby,
DE1 1LA
Tel: 01332 895984
Mobile: 07746117191
Email: [email protected]
Email: [email protected]
Adult social care
People Services
Derby City Council
The Council House
Corporation Street
Derby
DE1 2FS
Phone: 01332 640777
Minicom: 01332 640666
Age Concern Derby & Derbyshire
15 Morledge, Derby DE1 2AW
Open today · 10am–4pm
Phone: 01332 343232
Adult Services / Teams
Name Contact Details
Emergency Duty Team / Out of
Hours
Telephone: 01332 786968
Minicom: 01332 785642
Text: 0789 0034081 (for deaf people only)
Fax: 01332 786965
Safeguarding (referrals) Telephone: 01332 642855
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Minicom: 01332 640666
Fax: 01332 643299
Derby's out of hours emergency social care service:
Telephone 01332 786968
Minicom 01332 785642
Fax 01332 786965
SMS text message number 07890 034081 (for Deaf
people only)
2. Other Services / Organisations
Police 101
Care Quality Commission 03000 616 161
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15. USEFUL FORMS
15.1. ERS-2-07 – SERVICE USER COMPLAINT RECORD FORM ERS-2-07 – Service User Complaint Record Form
Etiquette Recruitment & Staffing Ltd
HEAD OFFICE ADDRESS
Office 3
9 Laurie House
Colyear Street
Derby,
DE1 1LA
Tel: 01332 895984
Mobile: 07746117191
Email: [email protected]
Name of Complainant:
Address:
Telephone number: Mobile number:
Email: Date of Complaint:
_________________________________________________________________________________________________
__________________________________________________________________________________________________
Complaint Details:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
_________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
_________________________________________________________________________________________________
__________________________________________________________________________________________________
Don’t forget to attach all necessary documentation
Proposed Action Purposes
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Don’t forget to attach all necessary documentation
Name & Signature:__________________________
Form Accepted by: [Authority Name Here]
Designation
Signature & Date: ____________________________________,
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Details of any evidences:
Don’t forget to include all documentation to validate your complaint.