Inspection on 14/03/07 for 149 Ash Street

This inspection was carried out on 14th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

149 Ash Street 12/03/09

149 Ash Street 07/08/06

149 Ash Street 01/09/05

149 Ash Street 31/05/05

149 Ash Street 16/09/04

149 Ash Street 18/05/04

Similar services:

Thorndene

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

Insight - Eastchurch

Southfields

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

CARE HOME ADULTS 18-65 Ash Street (149) Ash Street (149) Ash Near Aldershot Surrey GU12 6LT Lead Inspector Deavanand Ramdas Unannounced Inspection 14th March 2007 10:30 Ash Street (149) DS0000013450.V329924.R02.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 Ash Street (149) DS0000013450.V329924.R02.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. Ash Street (149) DS0000013450.V329924.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ash Street (149) Address Ash Street (149) Ash Near Aldershot Surrey GU12 6LT 01252 330529 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) jill.woolley@new-support.gov.uk www.new-support.org.uk New Support Options Limited Jill Woolley Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Ash Street (149) DS0000013450.V329924.R02.S.doc Version 5.2 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 7th August 2006 Date of last inspection Brief Description of the Service: The home is registered with the Commission for Social Care Inspection to provide accommodation and care to five service users with a learning disability. The home is located in a residential area close to public amenities and other facilities. Accommodation is on two floors accessed by stairs and comprises of an office, two lounges, dining room, breakfast area, bathrooms, toilets, laundry facilities and five single bedrooms. The home has a garden which is secure and accessible with private parking available. The range of fees charged by the home is £1196.00 to £1214.00 weekly. Ash Street (149) DS0000013450.V329924.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes site visit as part of the key inspection process by the Commission for Social Care Inspection henceforth referred to as the CSCI and carried out by Mr. D. Ramdas regulation inspector. The inspection commenced at 10:30 hrs and finished at 15:30 hrs and included a tour of the premises, interviews with staff and service users, and a review of documents and care records. The inspector noted service users required support with communication and in the absence of verbal feedback judgements were made about them based of their mood, behaviour and information given by staff. The inspector would like to thank the area manager, registered manager, staff and service users for their contribution to the inspection. What the service does well: The home has good needs assessment and excellent person centred plans. A health care professional recorded ‘‘I have seen such good individual lifestyle plans’’ and during discussions a member of staff commented ‘‘I do like the fact that service users go out a lot’’. Observations confirmed service users had good personal hygiene and were appropriately dressed to reflect their individuality and choice recorded in person centred plans. The home values equality and diversity and person centred plans reflected the unique needs of individual service users. The inspector noted staff have an understanding of the disability of service users and information about complaints, meals and access to records were in a pictorial format to make the information understandable to service users. Activities at the home are well planned and organised and based on the active support model which is a system for engaging service users in activities of daily living including domestic tasks and community activities. During discussions a member of staff stated ‘‘the home has plenty of activities and we have a staff on flex-shift to do one to one support’’. Observations confirmed service users accessed the community for lunch and were happy, relaxed and smiling. Meals at the home are good and offer variety, choice and healthy eating options. During discussions a member of staff stated ‘‘we sit down with service users to plan the menu of their choice’’. The home has good complaints and protection procedures with information in a pictorial format to make it understandable to service users. The inspector noted no complaints nor safeguarding adult matters were recorded about the home and observations confirmed service users were relaxed and comfortable in the presence of staff. During discussions a member of staff stated ‘‘I am aware of the policies and know how to make a complaint’’. Ash Street (149) DS0000013450.V329924.R02.S.doc Version 5.2 Page 6 Induction at the home is well planned and organised and new employees have a named mentor for the duration of their induction. During discussions a member of staff stated ‘‘when I joined the home I had a welcome pack and a mentor’’. The home has an experienced manager who provides management stability, leadership and direction to the staff team. The manager has completed a leadership course and is aware of her role and responsibilities with clear lines of communication and accountability in the home. During discussions a member of staff commented ‘‘the home is nicely managed, good. If I have any problems I can see the manager’’. What has improved since the last inspection? What they could do better: The registered manager must review the home’s fire precautions in consultation with the fire authority to promote safety and safeguard the welfare of service users. The home must strengthen recruitment and vetting practices to protect service users from harm. A number of recommendations have been made in the areas of medication and staff recruitment to promote good practice. Ash Street (149) DS0000013450.V329924.R02.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. Ash Street (149) DS0000013450.V329924.R02.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 Ash Street (149) DS0000013450.V329924.R02.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for assessing needs are good ensuring prospective service users’ individual aspirations and needs are assessed. EVIDENCE: The manager stated prospective service users would be admitted to the home on the basis of a full assessment of needs. The inspector noted the home had a policy on assessing needs and a pre-assessment checklist which covered personal care, health needs and social support. The manager confirmed prospective service users would have the opportunity to visit the home and a review of records indicated the home had individual care plans based on community care assessments and involving care managers, carers, families and service users. During discussions a member of staff stated ‘‘care is good’’ and observations confirmed service users had good personal care. Ash Street (149) DS0000013450.V329924.R02.S.doc Version 5.2 Page 10 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 planning and decision making is good reflecting the changing needs and personal goals of service users and ensuring service users make decisions about their lives with assistance as needed. The arrangements for risk taking are good enabling service user to take risks as part of an independent lifestyle. EVIDENCE: The home had person centred plans based on essential life style planning and reflected the individual and unique needs of service users. Care plans were drawn up with the involvement of service users, families, friends and other relevant professionals and in a pictorial format to make the information understandable to service users. Further evidence confirmed the home had a key worker system to promote continuity of care and care plans included risk assessments and one to one communication support. The inspector noted person centred plans are regularly reviewed to reflect the changing needs of service users and it is recorded ‘‘I have seen such good essential lifestyle plans’’. Ash Street (149) DS0000013450.V329924.R02.S.doc Version 5.2 Page 11 The home promoted decision- making and staff respected service users’ right to make choices reflected in person centred plans. The inspector noted the manager and staff had an understanding of the disability of service users with information about complaints, rights and abuse in a pictorial format to enable decision making in the home. Person centred plans confirmed service users were involved in regular meetings and assisted to make decisions about their own lives including activities and meals. The home had a policy on risk assessment and a missing person procedure to respond to unexplained absences by service users. The inspector sampled risk assessments which promoted the independence of service users to access community facilities and promote safety and choice. Observations confirmed service users had access to the fridge and kitchen facilities and during discussions a member of staff stated ‘‘the home has plenty of activities and we have a staff on flexi-shift to do one to one support’’. Ash Street (149) DS0000013450.V329924.R02.S.doc Version 5.2 Page 12 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): 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. The arrangements for occupation, community participation and maintaining personal relationships are good ensuring service users take part in valued and fulfilling activities. Meals at the home are good and offer variety, choice and healthy eating options. EVIDENCE: The manager stated service users participated in valued and fulfilling activities. A review of records confirmed service users have individual activity plans which reflected art, drama, sensory and other relevant and appropriate activities. The inspector noted one service user attended a day centre and had input from an art therapist with paintings on display in the home. During discussions a member of staff stated ‘‘I do like the fact service users go out a lot’’. The home promoted community links and a review of records confirmed service users accessed local facilities including pubs, cinemas, libraries and shops using public transport. Ash Street (149) DS0000013450.V329924.R02.S.doc Version 5.2 Page 13 During discussions the manager stated the home had a neighbourly relationship with the community and observations confirmed the home had its own transport to facilitate community access. The manager stated staff supported service users to maintain family links and the home had a visitor’s policy with no restrictions on visiting times. A review of records confirmed service users visited family and friends with assistance from staff and the manager stated service users could see visitors in the privacy of their rooms, if necessary. Observations confirmed service users had unrestricted access to bedrooms reflected in person centred plans. The home promoted the independence of service users and had daily routines reflected in active support plans. Observations confirmed staff addressed service users by their preferred names and the manager knocked on doors before entering bedrooms and bathrooms. Service users had unrestricted access to the home and staff interacted appropriately with service users in the lounge, dining area and kitchen. The inspector noted staff and service users having mid-afternoon tea in the kitchen and discussing activities. The manager stated the home had written menu plans which offered variety, choice and healthy eating options. Service users are involved in planning the menu using pictures to indicate choice of meals with one service user having special dietary requirements. On the day of the inspection service users had lunch in the community and the inspector noted the evening meal was lasagne with salad and a choice of fresh fruits or yogurt for dessert. During discussions a member of staff stated ‘‘we sit down with service users on Sunday to plan the menu of their choice’’. Ash Street (149) DS0000013450.V329924.R02.S.doc Version 5.2 Page 14 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. The arrangements for personal support are excellent ensuring service users receive personal support in the way they prefer and require. Access to health care is good ensuring service users’ physical and emotional health needs are met and medication management promotes the health and welfare of service users. EVIDENCE: The manager stated the home provided flexible personal support and a review of person centred plans confirmed individual routines describing likes, dislikes, communication profiles and times for getting up and going to bed. Observations confirmed service users had good personal hygiene and were appropriately dressed reflecting their choice and individuality. The inspector noted a service user was given personal care by a staff of the same gender recorded in person centred plans. The manager stated the home had arrangements for meeting the health care needs of service users. A review of records confirmed the home had health action plans and service users were registered with a local GP (General Practitioner) and had access to dental, chiropody and optical services as Ash Street (149) DS0000013450.V329924.R02.S.doc Version 5.2 Page 15 required. Further evidence confirmed the home had input from the specialist support team, psychiatrist, physiotherapist and neurologist to advise on the management of a service user with a medical condition. The inspector noted the home accessed the local PCT (Primary Care Trust) for emergency health care and a relative recorded ‘‘thank you for all the support you have shown with dental care and treatment’’. The home had a policy on medications, medical profiles with risk assessments and a service level agreement with a local chemist to supply medications to the home. Observations confirmed the home had adequate storage and kept a record of medications received by and disposed of to prevent mishandling of medications. Medication record sheets were dated and signed by staff and a review of training records confirmed staff have training in medications to safeguard the welfare of service users and promote health. Following discussions with the manager recommendations have been made for hand written prescriptions on medication record sheets to be dated, signed and witnessed by a second member of staff. In addition, medication in liquid form to be dated once opened to promote good practice. Ash Street (149) DS0000013450.V329924.R02.S.doc Version 5.2 Page 16 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. The complaint process is good ensuring service users feel their views are listened to and acted upon. The arrangements for protection are good and safeguard the welfare of service users. EVIDENCE: The manager stated the home had information on complaints and a review of documents confirmed the home had a policy on complaints and kept a record of complaints about the home. The inspector noted no complaints were recorded about the home since the last inspection by the CSCI and during discussions a member of staff stated ‘‘I am aware of the policies and know how to make a complaint’’. Observations confirmed service users moved freely in the home and were happy, smiling and comfortable in the presence of staff. As previously stated, information about complaints is in a pictorial format to make the process understandable to service users. The home had a policy on safeguarding adults and a copy of the local authority (Surrey County Council) procedures on safeguarding adults. A review of records confirmed staff have training in safeguarding adults and autism focus training to ensure the emotional needs of service users are understood and dealt with appropriately. Ash Street (149) DS0000013450.V329924.R02.S.doc Version 5.2 Page 17 Further evidence confirmed the home had a whistle blowing policy with no safeguarding adult matters recorded about the home since the last inspection by the CSCI. Observations confirmed staff treated service users with dignity and respect reflected in person centred plans. Ash Street (149) DS0000013450.V329924.R02.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 adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for the environment need strengthening to provide a safe and comfortable home for service users in which to live in. The systems for hygiene are good ensuring the home is clean and hygienic for staff and service users. EVIDENCE: The home is suitable for its stated purpose and in keeping with the local community. Observations confirmed the home had adequate furniture and fittings with a satisfactory standard of décor. The inspector noted improvements to the premises which included the decoration of two bedrooms, repair to window sills and the installation of window restrictors, new front door, repair to flooring and new work surface in the kitchen. The inspector had a discussion with the area manager of the company who stated a meeting has been arranged on the 16/3/07 with the housing association involved. The purpose of the meeting is to progress outstanding maintenance work which included improvements to the roof, flooring and utility room to safeguard the welfare of service users. Ash Street (149) DS0000013450.V329924.R02.S.doc Version 5.2 Page 19 On the day of the inspection the home was clean, well ventilated and free from offensive odours. Observations confirmed the home had a washing machine, dryer and hand washing facilities were prominently sited. A review of records indicated the home had a service level agreement with an approved contractor for the disposal of clinical waste and staff have infection control training to promote health. The inspector noted the home had gloves, aprons and observations indicated staff washed their hands regularly to prevent the spread of infection in the home. Ash Street (149) DS0000013450.V329924.R02.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): 32,34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing are good ensuring service users are supported by competent staff. Recruitment and vetting practices need strengthening to safeguard the welfare of service users. Induction training for staff is good ensuring service users joint needs are met by appropriately trained staff. EVIDENCE: The manager stated service users are supported by competent staff and observations confirmed staff are accessible to, approachable by, and comfortable with service users. A review of records confirmed staff have autism focus training and other relevant training including active support, intensive interaction and training in epilepsy to meet the needs of service users. The manager confirmed the home had undertaken a training needs analysis and the inspector noted the company had a training brochure and assessment centre to address staff training needs in National Vocational Qualification henceforth referred to as NVQ. The manager stated the home had a policy on recruitment and confirmed prospective employees are vetted by the home to safeguard the welfare of Ash Street (149) DS0000013450.V329924.R02.S.doc Version 5.2 Page 21 service users. The inspector sampled staff recruitment files which included completed application forms, written references, statement of terms and conditions, job descriptions, CRB (Criminal Record Bureau) disclosure information and training records. Following discussions with the manager a requirement has been made for staff recruitment files to include a recent photograph of the employee to safeguard the welfare of service users. In addition, a recommendation has been made for employees to be given a copy of the GSCC (General Social Care Council) code of conduct to promote good practice. The home has an induction and foundation training programme for staff and an induction checklist which included a confidentiality agreement, personal information and staff guidelines. The inspector noted induction covered orientation to the service, health and safety, policies and procedures and new employees had a named mentor for the duration of their induction programme. Further evidence confirmed the home had a policy on equal opportunities and staff have training in equal opportunities and diversity. As previously stated, staff have training in active support, intensive interaction and autism focus training which are linked to the home’s service aims and to service users’ needs. During discussions a member of staff stated ‘‘when I joined the home I had a welcome pack and a mentor’’. Ash Street (149) DS0000013450.V329924.R02.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. The arrangements for day to day operations are good ensuring service users benefit from a well run home. The systems for quality assurance are good ensuring service users participate in the review of the home. Health and safety needs strengthening to safeguard the welfare of service users. EVIDENCE: The home has a registered manager who provides management stability, leadership and direction to the staff team. The manager is aware of her role and responsibilities with clear lines of communication and accountability in the home. During discussions a member of staff stated ‘‘the home is nicely managed, good. If I have any problems I can see the manager’’. The inspector noted the manager has completed a course in leadership and is involved in developing the equality and diversity agenda within the company. Ash Street (149) DS0000013450.V329924.R02.S.doc Version 5.2 Page 23 The home has a policy on quality assurance and regular monitoring visits to safeguard the welfare of service users. Further evidence indicated the company used questionnaires to obtain feedback about the home with a report available for information. The inspector noted the home had regular meetings with service users and management action has been taken to meet requirements made by the CSCI to safeguard the interests of service users. The home had a policy on health and safety and staff have training in health and safety, fire safety, first aid, food hygiene and other relevant and appropriate training. Further evidence confirmed the home had a policy on COSHH (Control of Substances Hazardous to Health) with risk assessments and data sheets. Service inspection records pertaining to fire equipment, small portable appliances and gas safety were current and valid. Observations confirmed the kitchen appeared clean and hygienic with appropriate food safety practices to promote the health of service users. The home kept a record of accident and injuries and information about health and safety was displayed in the office. A review of records confirmed the home had regular fire alarm tests and monitoring of water temperatures to promote health and safety. Following discussions with the manager a requirement has been made for the home to have an up to date fire safety risk assessment to safeguard the welfare of staff and service users. Ash Street (149) DS0000013450.V329924.R02.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 x 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 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 x 3 x 3 x x 2 x Ash Street (149) DS0000013450.V329924.R02.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 YA34 Regulation 7,9,19 Schedule 2 Requirement The registered person must ensure that the home has all the required information regarding persons employed including a recent photograph to safeguard the welfare of service users. The registered person in consultation with the local fire authority must review fire precautions at the home to promote safety and safeguard the welfare of service users. Timescale for action 01/05/07 1 YA42 23(4)(v) 01/06/07 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 YA20 Good Practice Recommendations The registered person shall consider ensuring hand written prescriptions on medication record sheets are dated, signed and witnessed by a second member of staff to promote good practice. The registered person shall consider ensuring medications in liquid form including suspensions and solutions are DS0000013450.V329924.R02.S.doc Version 5.2 Page 26 2 YA20 Ash Street (149) 3 YA34 dated once opened to promote good practice. The registered person shall consider ensuring staff have copies of the GSCC (General Social Care Council) code of conduct to promote good practice. Ash Street (149) DS0000013450.V329924.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Burgner House 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ash Street (149) DS0000013450.V329924.R02.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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