Inspection on 27/08/08 for Ashgrange House

This is the latest available inspection report for this service, carried out on 27th August 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashgrange House 12/12/05

Ashgrange House 12/07/05

Ashgrange House 18/01/05

Ashgrange House 07/06/04

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Insight - Eastchurch

Southfields

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Seabourne House

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOME ADULTS 18-65 Ashgrange House 9 De Roos Road Eastbourne East Sussex BN21 2QA Lead Inspector Lucy Green Unannounced Inspection 27th August 2008 10:00 Ashgrange House DS0000021430.V367327.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 Ashgrange House DS0000021430.V367327.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. Ashgrange House DS0000021430.V367327.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashgrange House Address 9 De Roos Road Eastbourne East Sussex BN21 2QA 01323 732544 01323 732544 ashgrangehouse@aol.com 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) Alliance Home Care (Learning Disabilities) Ltd Care Home 8 Category(ies) of Learning disability (0) registration, with number of places Ashgrange House DS0000021430.V367327.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 - PC 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 - LD The maximum number of service users who can be accommodated is: 8 20th February 2007 Date of last inspection Brief Description of the Service: Ashgrange House is registered to provide personal care for up to eight people with learning disabilities. The home is a detached property situated in a quiet residential area of Eastbourne, approximately half a mile from the town centre. Local shops and bus routes are a short walk away. Accommodation is provided on three floors, the home does not have a lift and therefore people accommodated at Ashgrange must be independently mobile. Resident accommodation consists of eight single bedrooms. Communal areas comprise of a lounge, dining room, kitchen, three bathrooms and four separate toilets. A large garden is situated to the rear of the home and street parking is available at the front of the home. There is currently no Registered Manager at this service, although a Manager is in post who confirmed that she will be submitting an application for registration with the CSCI. More detailed information about the services provided at Ashgrange House, including the range of fees can be found in the home’s Statement of Purpose and Service User Guide - copies of these documents can be obtained directly from the Provider. Latest CSCI inspection reports are on available on request from the home. Ashgrange House DS0000021430.V367327.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulations 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at Ashgrange House are referred to as ‘residents’. This report reflects a key inspection based on the collation of information received since the last inspection, a review of the home’s Annual Quality Assurance Assessment and an unannounced site visit which lasted five hours on Wednesday 27th August 2008 between the hours of 10am and 3pm. The site visit included a partial tour of the premises and an examination of some care, medication and staffing records. The Inspector observed the interaction between staff and residents as they planned activities and prepared and served the lunchtime meal. Throughout the inspection process, the Inspector met and spoke with six of the people living at the home. Private conversations were had with two residents. The Inspector spent time with the Manager and Deputy Manager and met two of the staff on duty. What the service does well: Residents benefit from the support of a team of staff who are committed to meeting their needs and who are enthusiastic about the services they provide. It was evident throughout the inspection that staff and management are flexible in their approach and make the most of the resources available to them. Residents have the opportunities to make real choices about their daily lives and how they spend their time. During the inspection, it was observed that people get up, eat, go out and spend their money how and when they want to. During a group discussion with the Inspector, residents expressed comments about the home including I like it here, Im settled and I dont want to move anywhere else. Ashgrange House has good systems in place to support prospective residents to visit and decide whether they would like to move to the home on a permanent basis. One person was visiting the home at the time of the inspection with a view to moving to the service in approximately three weeks Ashgrange House DS0000021430.V367327.R01.S.doc Version 5.2 Page 6 time. This person told the Inspector I want to move here. I prefer Eastbourne to Bexhill. It was evident that this individual had been given the time to get to know the home, the other people who live there and the staff who will be supporting them. The home has systems in place to ensure that residents’ care needs are met and that they have access to a range of appropriate practitioners. The management team are open in their approach and actively seek the input and support of other professionals. Residents have access to a range of socially and educationally appropriate activities and have the opportunity to go on holiday each year and to visit places of interest. What has improved since the last inspection? What they could do better: Ashgrange House is currently providing good outcomes to the people it supports and this is evidenced by the very few requirements that have been made as a result of this inspection. In order to move the service further forward, the care planning system needs to be developed with a more accessible and person led approach. A particular emphasis should be on the strategic setting and monitoring of meaningful goals that enable residents to attain both short and long term objectives. Comprehensive health action plans for residents that are in line with the ‘Valuing People’ recommendations also need to be introduced. Ashgrange House DS0000021430.V367327.R01.S.doc Version 5.2 Page 7 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. Ashgrange House DS0000021430.V367327.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 Ashgrange House DS0000021430.V367327.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): 2&3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents benefit from an admission process that ensures their individual needs and aspirations are appropriately assessed prior to moving into the home. EVIDENCE: There have been two admissions to Ashgrange House since the last inspection in February 2007. The assessment information for both of these people was viewed. This provided evidence that a thorough assessment process had been undertaken prior to both individuals coming to live at the home. Documentation showed that information had been gathered from a variety of sources, which also included the opportunity for the resident to identify their own needs. There was evidence of detailed transition plans having been put in place that included visits to the home prior to admission, including several overnight stays. Discussion with the Manager confirmed that both new residents have settled in well Ashgrange House. The Inspector had a long conversation with one of Ashgrange House DS0000021430.V367327.R01.S.doc Version 5.2 Page 10 these two of these people who stated that they really liked living at the home. The review process has highlighted that these individuals have developed their skills since moving in and that there are clear plans in place to support them. Another prospective resident was visiting the home on the day of the inspection and it was clear that a structured transition programme was also in place for this individual. This person told the Inspector that they were looking forward to moving to Ashgrange House on a permanent basis and that they were in the process of choosing the paint colour to decorate their new bedroom. The Inspector was able to establish from the documentation in place and discussion with relevant parties that the information gathered at the assessment stage is used to inform a comprehensive care plan which evidences that the home can meet these individuals’ needs. Ashgrange House DS0000021430.V367327.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 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans include detailed information and guidelines to support individuals. Residents benefit from consultation about their care and opportunities to take managed risks. Outcomes would however be further improved if care plans were more person centred and strategically used to formulate life goals and develop skills. EVIDENCE: Through discussion with staff and observation of their practices, it was demonstrated that they have positive relationships with the people they support and a good understanding of their needs. The Inspector tracked the care for three residents, which included a partial examination of their care plans, activity schedules and a discussion with the Manager. The Inspectors also met with two of these residents during the course of the inspection. Ashgrange House DS0000021430.V367327.R01.S.doc Version 5.2 Page 12 The information currently in place provides detailed support guidelines about daily care needs, including a range of risk assessments and behavioural support needs. This approach to care planning however, does not demonstrate how the home supports residents to strategically formulate life goals and develop their independence. The documentation is also not entirely person centred and as such staff need to work with residents to record information about them from the view of the individual. Staff must also ensure that all entries to the care plan are signed and dated. Conversation with the Manager and Deputy Manager demonstrated a knowledge and understanding of what was necessary to move the care planning system forward. It was agreed that this is an important piece of work to be completed and in order for this to be undertaken in a meaningful way a requirement has been made with a compliance timescale of six months. It is expected that the Manager will detail the work that has been undertaken in this area in the next Annual Quality Assurance Assessment. The home has a system for reviewing residents’ care on a six-monthly basis, although the Manager did acknowledge that two residents reviews are currently overdue. The Manager explained that this was due to a number of other pressures on the service, but that reviews are now scheduled to be back on track. It was also evident that where residents’ needs had changed, the home had responded quickly and made the necessary referrals and therefore were not waiting for the review time to take action. As such no requirement has been on this occasion, but this area will be assessed again at the next inspection. Ashgrange House DS0000021430.V367327.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, 13,15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from the opportunities to access the local community and to participate in educational, social and meaningful activities. Residents are supported to maintain and develop relationships with other people and receive a range of balanced and wholesome food. EVIDENCE: Activity timetables identified that residents have access to a range of social and educational activities that are meaningful to them. On the morning of the inspection, one resident was at a work placement, two residents went shopping, another went out to purchase a newspaper which he then spent time reading, one person was supported to a attend a healthcare appointment and the other two residents undertook their own morning routines at home. One of these individuals, chose to spend time with the Manager and Ashgrange House DS0000021430.V367327.R01.S.doc Version 5.2 Page 14 the Inspector and facilitated part of the inspection process. In the afternoon, two residents went out horse riding, one person was planning to go to the fairground and two residents went out for coffee. Discussion with one resident provided information that they attend college and they told the Inspector that they really enjoy their art course. Another resident spoke of their employment at a local centre two days a week. It was evident both from an examination of activity timetables and observation of daily routines that residents are fully consulted about how they spend their time and that wherever possible their requests to go out are facilitated. In order to develop excellent outcomes in this area, the Manager is aware that the home needs to demonstrate how the activities and goal planning are linked to person centred plans of care which support individuals to achieve live goals and maximum independence. The home has a positive approach to enabling residents to maintain contact and relationships with families and friends. There is evidence in the care plans that the home supports residents to meet with and receive visits from their relatives and friends. Discussion with the Manager and observation of staff practices confirmed that the home understands the importance of good relationships with relatives and friends. Resident reviews include the opportunity for residents’ relatives/representatives to attend if the resident wishes. Meals at Ashgrange House are prepared according to a menu that is drawn up in consultation with residents to reflect the meals they wish to have. The menu is also reflective of individual likes and dislikes and specialist diets, therefore on some days different meals are prepared for different residents. The menu displayed included a range of varied and well-balanced meals. A pictorial menu system has also been devised to enable some of the residents to make their menu choices clearly known. The Inspector observed the preparation and serving of the lunchtime meal. Each resident was individually asked what they would like to eat from a choice of two options. The meals served were appetising, appealing and enjoyed by all. Ashgrange House DS0000021430.V367327.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported with their health and personal care needs in a professional and sensitive manner, although would benefit from the introduction of health action plans. Residents are better protected by the new systems in place to manage medication. EVIDENCE: Care plans provide documentary evidence that personal and healthcare needs are being met. It was evident that appropriate referrals are made to external professionals, including GP’s, dieticians and the community learning disability team. There was evidence for the residents case tracked, that they are regularly weighed and records maintained. Personal care was observed to be being provided in a sensitive and respectful way during the course of the inspection. The home has not currently introduced health action plans in line with the Valuing People White Paper. Whilst care plans provide detailed information about health care support, it is required that these action plans are introduced. Ashgrange House DS0000021430.V367327.R01.S.doc Version 5.2 Page 16 Medication systems were assessed by way of a review of records, storage and discussion with the Manager and Deputy Manager. The medication policy was not inspected on this occasion, although the Manager and Deputy Manager explained the new procedure that has been put in place to rectify the previous mistakes that have occurred in respect of medication. The administration, recording and storage of medication were judged to be satisfactory and guidelines were found to be in place regarding the use of ‘prn’ medication. The Manager reported that staff undertake medication training with the supplying pharmacy and undertake in-house competency assessments and confirmed that no staff handle medication until they have successfully completed this training. Ashgrange House DS0000021430.V367327.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 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from the systems in place to listen to their views and safeguard them from harm. EVIDENCE: The home has a complaints procedure in place and an accessible copy is kept on display for residents’ and visitors to access. The home has received two complaints in the last twelve months and evidence showed that both had been satisfactorily resolved. The CSCI has not received any complaints about the service at Ashgrange House since the last inspection. The home seeks to operate an open culture where issues are openly discussed and opinions shared. Positive interaction was observed between residents and staff during the inspection. Residents are encouraged to voice their opinions about the things they like and dislike. The home has a number of systems in place to protect residents from abuse. New staff are employed subject to robust recruitment procedures and the necessary checks being undertaken. There are appropriate systems for supporting residents’ with their finances. The training files viewed for three staff identified they had received training in the safeguarding of vulnerable adults. Ashgrange House DS0000021430.V367327.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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a safe and comfortable environment that meets their needs and is fit for the stated purpose of the home. EVIDENCE: The Inspector undertook a partial tour of the home, which included the communal areas and one bedroom. The remaining bedrooms were locked due to residents being out or residents requesting for them not to be entered and therefore these rooms were not seen. Ashgrange is a spacious house that is laid out over three floors. Resident accommodation comprises of eight single bedrooms. The resident who showed the Inspector their bedroom confirmed that they had chosen the colour and decoration of the room. Ashgrange House DS0000021430.V367327.R01.S.doc Version 5.2 Page 19 The kitchen, lounge and dining room provide residents with sufficient communal space to meet their needs. Discussion with the Manager highlighted that the garden has been developed and pathway paved since the last inspection and some of the residents are now involved in a garden project. Other improvements since the last inspection have included the installation of a new boiler and the total redecoration and refurbishment of the lounge. The home was found to be clean, tidy and hygienic at the time of the inspection. There is evidence of an ongoing programme of maintenance and redecoration and whilst there are parts of the home that require attention, these are not currently impacting on health and safety and the Inspector is satisfied that there is an appropriate plan in place. Ashgrange House DS0000021430.V367327.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): 33, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a dedicated and competent team of staff and are protected by the recruitment procedures. Staff have both the skills and support to enable them to perform their roles effectively. EVIDENCE: At the time of the inspection, the atmosphere was observed to be friendly and relaxed and the positive relationships between staff and residents were obvious. The home was staffed by three carers and the Manager at the time of the inspection and this was the usual ratio according to the rota. The Manager explained that whilst she is usually supernumerary on the rota, she is available to work on shift as required and this was evident at key times throughout the inspection. Staffing levels were adequate for the needs of the residents at the time of the Inspectors visit. Ashgrange House DS0000021430.V367327.R01.S.doc Version 5.2 Page 21 Discussion with the Manager and examination of three staff files identified that staff training is ongoing. There is documentary evidence that new staff members complete an induction programme in line with Skills for Care. Staff files also provide evidence of a robust system of recruitment being in place – with all the correct documentation and checks being in situ. Staff have access to a raft of mandatory and specialist training including; fire safety, first aid, safeguarding, epilepsy, manual handling, makaton, diabetes and sexuality. The Inspector saw evidence of regular staff meetings being conducted with minutes recorded. Whilst there is a system in place for supervising staff, these formal sessions are not always occurring at least every eight weeks. The Manager was open about this fact and stated that this was an area she knew needed to be improved. That being said, it was evident throughout the inspection that the Manager and Deputy Manager operate an open door style of management and therefore staff are receiving the appropriate level of support, guidance and leadership. Ashgrange House DS0000021430.V367327.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from the home being run by an experienced and dedicated Manager who ensures that the home is run safely. The organisation has systems in place to self-audit and monitor. EVIDENCE: The previous Deputy Manager was promoted to Manager just before the last inspection. At the current time, this individual is still not registered with the Commission, although the Manager did show the Inspector her completed application form which she confirmed would be submitted immediately. The Commission has since received this application which is now being processed. Ashgrange House DS0000021430.V367327.R01.S.doc Version 5.2 Page 23 During the inspection, it was observed that the Manager had a good relationship with both staff and residents and it was apparent that both found her approachable and supportive. The home has a system of quality monitoring in place with the Area Manager conducting regular visits in accordance with Regulation 26. There is also evidence that annual satisfaction surveys are sent out to stakeholders, although at the current time the results of these have not been formally collated and published. The home has various systems in place to ensure the health and safety of the home are maintained. The Inspector sampled some of the records in respect of fire safety, the testing of portable appliances and prevention of legionnaires and as such concluded that the home has satisfactory recording and monitoring systems in place. Ashgrange House DS0000021430.V367327.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 2 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 X 3 X X 3 X Ashgrange House DS0000021430.V367327.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. 1 Standard YA6 Regulation 15(1)&(2) Requirement The Registered Person must ensure that care plans are accessible documents and developed in consultation with the service users in a person centred way. The Registered Person must ensure that service users are supported to set, monitor and achieve both their long and short term goals and aspirations. The Registered Person must ensure that each service user has a comprehensive health action plan in place which is in line with the Valuing People White Paper. Timescale for action 01/02/09 2 YA11 15(2) 01/12/08 3 YA19 12(1) 01/12/08 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 All staff should receive formal and recorded supervision DS0000021430.V367327.R01.S.doc Version 5.2 Page 26 Ashgrange House sessions at least every two months. Ashgrange House DS0000021430.V367327.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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. 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