Inspection on 01/09/05 for 149 Ash Street

This inspection was carried out on 1st September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

149 Ash Street 12/03/09

149 Ash Street 14/03/07

149 Ash Street 07/08/06

149 Ash Street 31/05/05

149 Ash Street 16/09/04

149 Ash Street 18/05/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Ash Street (149) 149 Ash Street Ash, Nr. Aldershot, Hampshire GU12 6LZ Lead Inspector Helen Dickens Announced 01 September 2005 09:30 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 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 Stationary 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. Ash Street (149) H58 S13450 149 Ash Street V240848 010905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 149 Ash Street Address 149 Ash Street Ash, Nr.Aldershot Hampshire GU12 6LZ 01252 330529 as telephone jill.woolley@new-support.org.uk New Support Options Limited 9/10 Commerce Park, Brunel Road, Theale, Berkshire, RG7 4AB Application in progress Care Home (CRH) 5 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Category(ies) of Learning disability (LD) 5 registration, with number of places Ash Street (149) H58 S13450 149 Ash Street V240848 010905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 The age/age range of the persons to be accommodated will be: 30-55 YEARS OF AGE Date of last inspection 31 May 2005 Brief Description of the Service: 149 Ash Street is a detached Victorian house in the town of Ash near Aldershot. The building is owned by London and Quadrant Housing Association and support and staffing is provided by New Support Options. The home offers support to five adults with learning disabilities, aged between 27 and 55 years.There are five single bedrooms, two lounges, a dining room, a breakfast area and three bathrooms available in the home. There is a large well-maintained garden available and some parking at the front of the home. The local shops are within walking distance. Ash Street (149) H58 S13450 149 Ash Street V240848 010905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over six and a half hours and was the second inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. The inspection was carried out by Helen Dickens, Lead Inspector for the service. Ms. Jill Woolley, Manager, represented the establishment. A tour of the premises took place. The inspector met and spoke to all residents and spent time with a small group during their regular menu planning meeting. The inspector spoke at length with two members of staff and examined a number of case files, documents and records during the course of the inspection. This was a very positive inspection. The inspector would like to thank the manager and staff, and especially the residents, for their time, assistance and hospitality. What the service does well: What has improved since the last inspection? The majority of requirements from the last inspection had been met including updating the service user guide and statement of purpose. A considerable amount of progress has been made on the personal planning paths and care plans of each resident, and these improvements will be documented in the main report. The inspector was very impressed by the new system for menu planning and was invited to join the residents for their weekly session. The commitment and enthusiasm from the member of staff who takes responsibility for this activity is commendable. Ash Street (149) H58 S13450 149 Ash Street V240848 010905 Stage 4.doc Version 1.40 Page 6 The home has improved its arrangements for resident’s meetings and especially the way residents receive feedback about the outcomes of their participation. The inspector has asked permission for the format to be shown, as an example of good practice, to other homes struggling to improve their arrangements in this very important area. The complaints procedure has been up-dated and user-friendly versions are posted throughout the home. A new bound complaints/compliments book has been created and so far a number of compliments have been received. There have not been any complaints. Risk assessments are particularly well done in this home and the manager has made more progress in up-dating these. One resident has made remarkable progress over the last several months. To protect the confidentiality of this resident, the improvements have been noted in the inspector’s own notebook, rather than highlighted in the main report. Staff roles and responsibilities have been further clarified and designated staff given responsibility for particular areas. The inspector noted a number of areas where this was working particularly well such as leisure activities, the administration of medication, arrangements for meals and menu planning, and health and safety matters. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Ash Street (149) H58 S13450 149 Ash Street V240848 010905 Stage 4.doc Version 1.40 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ash Street (149) H58 S13450 149 Ash Street V240848 010905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Ash Street (149) H58 S13450 149 Ash Street V240848 010905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3 and 5 Residents moving to 149 Ash Street have sufficient information made available to them about the home, and they can be confident that their needs and aspirations will be properly identified and met. EVIDENCE: The statement of purpose and service user’s guide have been up-dated and revised since the last inspection. Both documents are in a very residentfriendly format including pictures as well as words, with photographs where appropriate. Each resident’s own bedroom is photographed for their own personal copy of the contract to highlight their right to occupy a particular room. The home have had difficulty locating the early assessments which were carried out on the long-standing residents before they were admitted to the home. Medical assessments from the health authority were available and quite detailed, but no assessments from social services could be obtained. As the absence of these documents does not appear to have impacted negatively on the well-being of residents, and many thorough assessments have been carried out since, no further requirements will be made in this respect. Staff at the home can demonstrate their capacity to meet resident’s needs in a number of ways. The inspector observed many examples of good communication between residents and staff during the day. Resident’s Ash Street (149) H58 S13450 149 Ash Street V240848 010905 Stage 4.doc Version 1.40 Page 10 reactions and body language indicated they responded well to staff and trusted them. The key worker system operates to the benefit of residents and those staff interviewed had excellent knowledge of each persons needs. Ash Street (149) H58 S13450 149 Ash Street V240848 010905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8 and 9 The system for care planning is sound and ensures residents changing needs are reflected in their personal plans. The home has also improved the way it consults residents. EVIDENCE: Personal planning paths and individual care plans continue to be up-dated and have improved since the last inspection. Dreams, goals and aspirations are noted and overall, resident’s plans are now in a format which is much more accessible to them. A very detailed life history is being compiled for each resident. Photographs of each resident’s family, education, interests and hobbies are highlighted and linked with a narrative which can then be read to residents. Staff have taken a great deal of trouble to research the detail of each resident’s ‘book’. The ’10 big questions’ which New Support Options is asking every resident to consider, are also listed, together with their responses and/or other evidence. Resident’s care plans, notes of resident’s meetings, and observations on the day of the inspection show that staff are working hard to provide as many opportunities as possible for residents to make decisions in their daily lives. Ash Street (149) H58 S13450 149 Ash Street V240848 010905 Stage 4.doc Version 1.40 Page 12 There have been a number of improvements in consultation with residents since the last inspection. New arrangements for menu planning are a good example and this is discussed later in the report. Another impressive example of improved consultation was the resident’s meetings notes. These now come in words and picture format. They are always restricted to one side of A4 and the top of the page has a border of scanned photographs of those residents who attended. Any staff who attended also have their photograph scanned in. All areas discussed have either a photograph or picture to illustrate the subject, e g holidays, work being done in the house, or activities. A new staff member who was going to start the following week had her photograph scanned in; this allowed residents to be able to visualise what she looked like as they were being told of her arrival. The agenda which comes out before the meeting is done in the same format and the final notes from each meeting are displayed on the resident’s notice board in the kitchen. In addition, key workers go through these in one-to-one sessions with residents. The ’10 big questions’ which New Support Options have introduced for all residents, is intended to inform the policies and planning of the wider organisation as well as homes at a local level. Risk assessments at this home are particularly well done and highlight the extent to which staff are enabling residents to take reasonable risks in their day to day lives. The format considers the benefits to each resident of being able to engage in various domestic and leisure activities and all those risk assessments inspected where fully completed and up-to-date. Ash Street (149) H58 S13450 149 Ash Street V240848 010905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14,15,16 and 17. The home encourages and enables residents to lead appropriate and fulfilling lifestyles both inside and outside the home. Arrangements for meals and menu planning have improved significantly since the last inspection. EVIDENCE: Residents have the opportunity to learn new skills and several residents have certificates of courses attended displayed in their rooms. There are also a variety of activities for residents who wish to take part; the recent resident’s meeting showed photographs of their karaoke party for example. The meeting notes also contained information about holidays: “Sharon also told us that our holidays had now been booked and reminded us who we were going with and where we were going to stay.” The notes went on to state who was going where and which members of staff would accompany them. New Support Options gives guidance to staff (on their intranet) about supporting residents who form personal and intimate relationships. The manager was knowledgeable on this subject and had considered the issues with regard to each resident. However, there were currently no such relationships within the home and, as several residents have an autistic Ash Street (149) H58 S13450 149 Ash Street V240848 010905 Stage 4.doc Version 1.40 Page 14 spectrum disorder, they do not in fact interact with each other very much at all. Daily routines were observed to promote the independence of residents and staff involved residents in conversations and activities as much as possible. There had been a marked improvement in the way residents were involved in mealtimes and menu-planning. One member of staff had been given the responsibility of organising this and the inspector joined their weekly menuplanning meeting. The home had obtained a large collection of laminated photographs of a variety of foods and these where placed on the table with residents being supported to make choices for the coming week. These were then displayed in the weekly menu planner as a reminder of what had been chosen and on which days. Residents showed the inspector their favourite foods and clearly got satisfaction from joining in with the planning. Special diets were catered for (one resident needed a coeliac diet, another required a low cholestoral diet, and yet another needed a low fat diet.) The overall focus was on healthy eating so low-fat options were chosen and the hot food was usually prepared using fresh ingredients. The staff member also had to consider the culinary confidence of the staff member on each shift and whether they would be happy to prepare particular dishes. The special food for one resident which needed to be kept apart from other foodstuffs like bread, cakes and flour, had been placed in a separate cupboard to prevent contamination. Some residents help with the shopping, and others have limited involvement with the cooking and laying of the table. Ash Street (149) H58 S13450 149 Ash Street V240848 010905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20 and 21 The arrangements for the administration of medication need some review in order to fully comply with this standard. The policies on ageing, illness and death of residents should ensure these issues are handled with respect by the home. EVIDENCE: Whilst the administration of medication at the home was generally well organised, there were some areas of concern which are described below. The staff were commended by the inspector for the careful and thorough procedures they had put into place to manage one resident’s frequent changes in medication. The twice yearly visit from a local pharmacist was overdue and the manager was asked to follow this up. There was also a discrepancy on a resident’s medicine administration record which meant there had been a medication error; this had not been reported to CSCI. The inspector also found a tablet on the floor in the office. The inspector recommended that a separate record be kept of any errors in the administration of medicines, this would enable the home to review procedures to help prevent further problems. The inspector reminded the manager that these errors should be reported to CSCI. Ash Street (149) H58 S13450 149 Ash Street V240848 010905 Stage 4.doc Version 1.40 Page 16 The home’s existing policy on the administration of medicines needs to be much clearer about how medicines are actually administered as there were different interpretations of the role of the ‘administrator’ and the role of the ‘witness’. The policy currently does not include CSCI in the list of people/organisations to be informed in the event of a drug error. Issues around illness, dying and death are treated sensitively within the home. Resident’s plans demonstrate that their wishes ( and those of their families/advocates) are taken into account. Ash Street (149) H58 S13450 149 Ash Street V240848 010905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 Resident’s can be confident that arrangements in this home for airing their views, and for protecting them from abuse and neglect, are satisfactory and likely to protect them from harm. EVIDENCE: The complaints procedure has been revised to include timescales for responding to complaints. A user-friendly version has been posted around the home so that residents and visitors are reminded of their right to raise issues and how this can be done. A bound comments/complaints book has been organised and this is kept in the office. Several comments, and no complaints, have been received since the last inspection. The arrangements for the protection of vulnerable adults were covered in the previous report and there have been no issues raised on this matter since the last inspection. Ash Street (149) H58 S13450 149 Ash Street V240848 010905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,27 and 30 The premises provides a homely environment but there are a number of outstanding maintenance issues which need addressing for the safety and comfort of residents. This home provides a clean and hygienic environment for its residents. EVIDENCE: Tiles in one bathroom had come off the wall, the boxed pipe cover needed decorating, and the cover on the hand basin plinth was damaged. There was paper peeling off the ceiling in another bathroom. A window surround still hadn’t been finished and this was a requirement from the last inspection. The tile on the side of one of the baths was cracked and held together with tape; this was also an outstanding requirement from the last inspection. One resident was still waiting for his window to be replaced, and the damaged skirting board in the dining room still hasn’t been repaired. One resident had a broken handle on the door. The stair carpet is worn at the back of each step which, whilst not particularly dangerous, is certainly unsightly. London and Quadrant Housing Association is responsible for most of these maintenance issues and there is evidence of many attempts by the home manager and area manager of New Support Options to put pressure on the Ash Street (149) H58 S13450 149 Ash Street V240848 010905 Stage 4.doc Version 1.40 Page 19 housing association to get these repairs done. However, failure to comply with Regulation 23 is an offence and CSCI may need to consider enforcement proceedings against the Registered Provider. The inspector observed that the staff consider the privacy and dignity of residents in their day to day dealings with them. The resident’s care plans had identified privacy and dignity issues and these were documented and wellmanaged. The inspector asked if instructions for toileting one resident could be made available in a more discreet manner as this was currently posted on the wall of the bathroom. On the day of the inspection the home was found to be clean and hygienic throughout and there were no offensive odours. One member of staff gave the inspector a tour of the laundry, highlighting satisfactory arrangements for dealing with soiled laundry and preventing the spread of infection. The remainder of the standards in this section were covered in the previous report. Ash Street (149) H58 S13450 149 Ash Street V240848 010905 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,35 and 36. Residents in this home benefit from clarity of staff roles and responsibilities. However, staff training needs to be reviewed urgently in order to continue to comply with the National Minimum Standards. EVIDENCE: The manager has delegated some specific areas of work to individual staff members and this has not only clarified roles and responsibilities for staff, but it has given them the opportunity to develop specific areas of expertise as mentioned earlier in the report. All staff have job descriptions and those spoken to were clear about their own roles. The staff were observed to interact well with residents and were motivated and committed. However, in order to meet Standard 32 in full, 50 of care staff must have NVQ 2 or above by the end of December 2005 and the manager said this was unlikely to be the case. The inspector confirmed with a senior colleague in CSCI that this standard still applies to all care homes. The home will therefore need to take advice on this matter and send their action plan to CSCI. The staff to resident ratio was appropriate on the day of the inspection but the inspector asked the home to calculate staff numbers according to the Ash Street (149) H58 S13450 149 Ash Street V240848 010905 Stage 4.doc Version 1.40 Page 21 Residential Forum matrix available from the Department of Health website. Resident’s are involved in recruiting new staff and interact with candidates during their visit to the home. The manager gave the example of a resident who shared some thoughts on their favourite things with the candidates; the manager said this was a good opportunity to see how candidates interacted with residents. The inspector took a note of the CRB numbers of existing staff. The training programme at the home needs to be reviewed to make sure that all staff are up-to-date with mandatory training. At least one staff member has fallen behind with nearly all mandatory training courses. The staff at the home are well supervised and supported. In addition to one to one supervision and staff meetings, a number of team building activities and training have been carried out since the last inspection. Ash Street (149) H58 S13450 149 Ash Street V240848 010905 Stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,39 and 42 Resident’s benefit from a well run home and can be confident that their views are taken into account in the quality monitoring systems at the home. The health, safety and welfare of residents is given priority by the manager and staff, but a number of minor health and safety matters needed attention. EVIDENCE: Resident’s benefit from a well run home and the manager and staff work well together to ensure the home meets its stated purpose. The manager still needs to complete her registration with CSCI and a date was booked for the fit persons interview later in the month. Quality assurance mechanisms at this home include Regulation 26 visits each month, management and independent audits, residents ‘Listen to me workbooks’ and the ’10 big questions’ mentioned earlier. Resident’s files demonstrate year on year improvements for each resident. Ash Street (149) H58 S13450 149 Ash Street V240848 010905 Stage 4.doc Version 1.40 Page 23 A number of minor health and safety issues were raised on the day of the inspection. No electrical wiring certificate could be found. There was no obvious evidence that a test for Legionella had been carried out recently. An old sofa was outside in the garden waiting to be collected by the council. The laundry room contained a bottle of laundry washing liquid which staff felt was safe but the inspector advised them to have a documented risk assessment on file. A toilet seat was found to be very loose and it was removed whilst the inspector was still in the building. In other respects health and safety issues were well managed. One staff member had been given responsibility for this and she was knowledgeable about the various aspects of health and safety as applied to care homes. The hazardous substances cupboard was locked, all water accessible to residents was controlled to around 43C and fire safety checks and appliances inspections were up to date. The arrangements in the kitchen demonstrated good practice in food handling and hygiene. Fridges and cupboards were examined and found to be clean, tidy and well-kept. Fridge and freezer temperatures were regularly recorded and within acceptable limits. There was a sealed packet of raw minced meat on a high shelf in the fridge. The member of staff who did this explained that her recent training on food hygiene permitted this, as long as the packets were sealed. The inspector recommended that raw meat should be on the lowest shelf and space was found at the bottom of the fridge. Ash Street (149) H58 S13450 149 Ash Street V240848 010905 Stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 x 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 4 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x x 3 x x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 4 Standard No 31 32 33 34 35 36 Score 3 2 2 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ash Street (149) Score x x 2 3 Standard No 37 38 39 40 41 42 43 Score 2 x 3 x x 1 x H58 S13450 149 Ash Street V240848 010905 Stage 4.doc Version 1.40 Page 25 yes 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 20.4 20.6 Regulation 13(2) 37(1)(e) Requirement The home must review its policies and procedures regarding the administration of medication and send the revised versions to CSCI. The review must include clarifying guidance to staff on recording, reporting and monitoring of medication errors, and on the respective roles of those who administer medication, as opposed to those who witness it. All drug errors must be reported to CSCI. The home must ensure that the twice yearly advisory visits from a pharmacist are carried out in a timely fashion. Outstanding maintenance issues (listed under Standard 24 in the report) must be pursued and remedied as quickly as possible as several of these are outstanding from the last inspection. The action plan must be sent to CSCI as the inspector may need to consider initiating enforcement procedures. The home must review its position regarding the number of staff expected to have NVQ 2 or above by the end of 2005. A Timescale for action 01.10.05 2. 20.12 13(2) 01.10.05 3. 24.1 23(2)(b) (d) 01.10.05 4. 32.6 18(1)(a) 01.11.05 Ash Street (149) H58 S13450 149 Ash Street V240848 010905 Stage 4.doc Version 1.40 Page 26 5. 33.3 6. 35.1 7. 37.1 8. 42.1 9. 42.3iii,iv. copy of this review and an action plan must be sent to CSCI. 18(1)(a) The manager must calculate the staff:resident ratio using the Residential Forum Guidance recommended by the Department of Health. This calculation should be sent to CSCI. 18(1)(a) The home must ensure that all staff are up to date with the mandatory training courses as discussed during the inspection. CSA The manager must complete the Section 11 Registered Manager application process and be registered with CSCI as soon as possible. 13(4)(a) The home must ensure that all (c) risks to residents are identified, assessed,and managed. An additional risk assessment for the laundry cleaning products in the laundry area is needed. A toilet seat which had become loose needs to be repaired or replaced. 13(4)(a), The home must produce (c) evidence of electrical wiring safety/inspection and compliance with Legionella regulations. 01.11.05 01.12.05 01.10.05 08.09.05 01.10.05 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 27.1 42.2 iv Good Practice Recommendations Any instructions to staff regarding toilet arrangements for residents, should be available in a way which protects the privacy and dignity of residents. Raw meat should always be stored on the lowest shelf in the refridgerator, even if it is in sealed packaging. Ash Street (149) H58 S13450 149 Ash Street V240848 010905 Stage 4.doc Version 1.40 Page 27 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ash Street (149) H58 S13450 149 Ash Street V240848 010905 Stage 4.doc Version 1.40 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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