Inspection on 23/05/05 for Aashna House

This inspection was carried out on 23rd May 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

Aashna House 02/10/07

Aashna House 15/05/06

Aashna House 27/10/05

Aashna House 05/11/04

Aashna House 30/06/04

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

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

CARE HOMES FOR OLDER PEOPLE Aashna House 2 Bates Crescent Off Abercairn Road Streatham, London SW16 5BP Lead Inspector Mary Magee Announced 23/05/2005 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 Older People. 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. Aashna House G52-G02 S22715 Aashna House V222790 230505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Aashna House Address ASRA Greater London Housing Association, 2 Bates Crescent, Off Abercairn Road, Streatham, London, SW16 5BP 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) 0208 765 0822 ASRA Greater London Housing Association Limited CRH Care Home 37 Category(ies) of PC Care Home only registration, with number of places Aashna House G52-G02 S22715 Aashna House V222790 230505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: To include the current service user aged 56 years Date of last inspection 5th November 2004 Brief Description of the Service: Aashna House is a purpose built residential care home providing care and accommodation for frail elderly people of Asian origin. It is situated within a ten-minute walk of local shops and public transport. It is located in a residential road in Streatham, South West London. Asra Greater London Housing Association own and manage the home. It is a very pleasant and spacious two-storey building with the added advantage of enclosed wellmaintained gardens to the rear. The house is divided into five units, each having its own dining room and small kitchen. The large catering kitchen is located on the ground floor. A passenger lift is also provided. The gardens and the buildings are wheelchair accessible. The home has 31 single bedrooms and 3 double bedrooms. Each room has an abundance of space with attached kitchenette and en-suite shower facility. A CCTV is provided by the front door. Aashna House G52-G02 S22715 Aashna House V222790 230505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was undertaken during the daytime. It lasted over seven hours. An interpreter assisted with discussions between seven service users and the inspector. Comment cards were also received from relatives, district nurses and care managers visiting the home. A number of records were viewed, these included care plans for service users and personnel details for staff. What the service does well: What has improved since the last inspection? What they could do better: The provider needs to make sure that staff receive suitable training and development to meet their individual training needs. Staff need to work more Aashna House G52-G02 S22715 Aashna House V222790 230505 Stage 4.doc Version 1.30 Page 6 closely with other professionals in the community especially the health service. They require more knowledge about health related issues that affect service users and need to know what to do in emergencies. Improvements are needed to care planning arrangements so that changes to individuals care needs are responded to. The home needs to have a monitoring system in place to determine how effective the home is overall in meeting the needs of service users. 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. Aashna House G52-G02 S22715 Aashna House V222790 230505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Aashna House G52-G02 S22715 Aashna House V222790 230505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 3 4 6 Service users are cared for by staff from their own culture, religion and ethnic group. Service users know that staff can talk with them in their first language. EVIDENCE: Holistic care to 37 elderly people of Asian origin is provided. The information on the services provided and how the home will meet the needs of these people in the service user’s guide. This is not available in any language other than in English. Considering that the large majority of service users accommodated do not have English as a first language the information provided is not adequate or in an appropriate format to enable prospective service users make an informed decision. Records of assessments and the care plans viewed for two service users admitted since the last inspection included good information. Written needs assessments and what the home must do to meet these needs were available for these individuals and had been completed by members of staff from the home. Copies of care management assessments were also included. Six service users spoke to the inspector. They said that they enjoyed living at the home. They reported on their satisfaction at living at such a pleasant and Aashna House G52-G02 S22715 Aashna House V222790 230505 Stage 4.doc Version 1.30 Page 9 comfortable home. They also stated that staff were kind and helpful and were able to communicate with them as a number of staff could converse in several languages. The home provides for the needs of elderly people of Asian origin, and service users reflect all backgrounds. Such diversity evident are service users with many languages and beliefs, Gujarat, Urdu, Punjabi, are some of the first languages spoken. Some of the religious practices observed by service users include Buddhism, Hinduism and Islam. The home demonstrates that it meets the specialist needs of service users admitted to live there. The needs and preferences of the cultural and religious groups are met by a staff team who have a good understanding of their religious and cultural needs. The home employs staff members with a variety of linguistic skills that enable them to communicate clearly on their needs. These range from Urdu and Gujarat to Hindu. Staff also share similar cultural backgrounds and have a good understanding and empathy with the older generation. The home does not accept people for intermediate care. Aashna House G52-G02 S22715 Aashna House V222790 230505 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 8 9 10 11 Service users have their personal and social care needs met by a sensitive and caring staff team. Staff require further training and support to ensure that the healthcare needs of service users are met. EVIDENCE: Service users and relatives said that they were happy with the care provided at the home. The inspector examined five care plans. Written care plans viewed at previous inspections were difficult to follow as the majority of staff do not have English as a first language. To ensure that care plans were clear and easily viewed all care plans were typed to overcome this. The care plans and risk assessments were up to date and had recently been reviewed. Records also indicated that these had been kept under review. Daily records maintained for service users included details of changes in conditions, consultations and appointments but further development is recommended on recording as much information as possible relating to the daily progress of individuals. Service users are allocated personal key workers. Their role is to support individuals with their care and maintain individual records and keep all changes updated. Although some of the notes were a little difficult to read it was evident that changes had been recorded and any issues identified responded Aashna House G52-G02 S22715 Aashna House V222790 230505 Stage 4.doc Version 1.30 Page 11 to. Team leaders are also notified of all changes and had taken responsibility for seeking advice from professionals. Three service users said that they found their key workers to be very helpful and kind. Handovers are thorough. One was in progress during the afternoon to which all staff attended. The inspector also met with the staff group. Feedback received indicated that staff were interested motivated and keen to provide the best service to people living at the home. They also showed an interest in learning more about looking after older people and developing their skills. Five service users also spoke about how secure they felt and how well staff understood them. There were records on files to indicate that regular weight checks were completed. One service user was feeling unwell and not interested in her meals. She was taking supplements and was recently seen by the hospital consultant. Her weights had not always been regularly recorded to indicate if further treatment was needed. Communication books for relatives have been placed in all service user’s bedrooms. Service users are registered with a number of GP practices and those of choice where possible. Two people said that they received a high quality of service from the GP, another service user said that her service was not so good at the GP practice. Regular three/six monthly meetings have commenced between GP practices, district nurses and senior staff at the home. Medication and individual service user reviews have also commenced. Senior care staff undertake the administration of medication. Although no errors were observed in medication administration procedures, the home has encountered difficulties with the dispensing of medication. Because there are a number of GP practices involved some are not linked electronically to the pharmacist for prescriptions. No pre printed MAR sheets were produced to the home from another pharmacist. This has resulted in delays by the home in and unnecessary demands on staff collecting medicines. The manager told the inspector of the plans to use the services of a large dispensing pharmacist in future. Medicines are to be placed in blister packs. Unfortunately, one GP practice has made the decision not to use the services of this pharmacist and therefore medicines for two service users will not be dispensed in the same manner. A number of service users self medicate. However, there are no risk management systems in place for this. This is detailed as a requirement. None of the service users had pressure sores. Pressure relieving equipment was observed for a number of service users, examples such as cushions and mattresses were provided. One lady had a leg ulcer and had the dressings changed every other day by the district nurse. There are a number of service users with insulin dependent diabetes. The district nurses visit the home to undertake blood sugar monitoring and administer insulin. Ten members of staff Aashna House G52-G02 S22715 Aashna House V222790 230505 Stage 4.doc Version 1.30 Page 12 have received training in monitoring blood sugars and in the action to take if there are indications that an individual is becoming hypoglycaemic. Despite this training emergency services and district nurses are regularly called to check the blood sugar recordings when staff are concerned. This task could be undertaken by competent trained staff care staff at the home and thus avoid unnecessary delays in treatment. Comment cards received from district nursing service indicated that staff are not fully aware of the needs of people with diabetes. Communication with district nurses is not as good as it should be. Nurses notes maintained are not linked in with the records and care plans held by the home for service users. Frequently care staff interpret for nurses visiting service users at the home but the information is not recorded or communicated to the staff team. The staff team reflect the cultural composition of service users. Records of assessments for service users included details of wishes to be observed at the end of life. Service users at this home have spacious bedrooms with their own shower facilities and toilets, thus enabling privacy and dignity. These bedrooms were designed and provided to meet the specific cultural needs of the service user group. A large number of service users have their own telephones. Service users were dressed in clothes that reflected their cultural and ethnic backgrounds. Staff were competent in communicating with service users in their mother tongue. Aashna House G52-G02 S22715 Aashna House V222790 230505 Stage 4.doc Version 1.30 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 13 15 Service users have their cultural and religious needs met by a staff team who have a good understanding of their culture and share similar ethnic origins and backgrounds. Meals served are varied and nutritious with a variety of nine different dietary preferences catered for daily. EVIDENCE: A characteristic feature of the home, observed and confirmed by staff and service users, is the way the home promotes a spiritual sensitivity and actively celebrates all religious feasts. Two weekly religious celebrations such as Bhajans and Sai Babas take place. Due to the size of the individual accommodation and additional facilities provided service users frequently choose to entertain in their own rooms. Four service users spoken to said that they liked to spend time in their own flatlet and that staff respected this wish. Observations made by the inspector were that service users played a key role in deciding about the lifestyle at the home. Service users were observed taking exercise on the spacious corridors and meeting and conversing with their neighbours in the reception area. Television with Asian channels is available to all service users in the communal lounge and in individual accommodation. Aashna House G52-G02 S22715 Aashna House V222790 230505 Stage 4.doc Version 1.30 Page 14 Feedback received from the care management team following recent reviews indicated that further development of the programme of activites should be encouraged. The home is divided into five units, each has it’s own dining room and kitchen. This is used also as a gathering place for friends. Mealtimes at the home are pleasant and relaxed with staff sharing mealtimes. Individual choices at mealtimes indicated that a minimum of seven different dietary preferences were acknowledged and catered for. The home employs two cooks every day who take pride in producing excellent meals that appeared nutritious and appetising. Meals served at the home offer great variety and meet individual dietary and cultural needs and preferences. Menus are displayed in dining rooms in two Asian languages. Service users spoke about changes introduced to food served at the home. They said that they had not been consulted on recent changes to evening meals. They were unhappy that the fresh fruit enjoyed by many was no longer available. The overall comments from service users indicated that people were happy with the main meals but that they would like more consultation regarding changes to provisions and for more fresh fruit to be available. Aashna House G52-G02 S22715 Aashna House V222790 230505 Stage 4.doc Version 1.30 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 18 Service users are listened to and given the opportunity to raise any issues of concern. Staff are knowledgeable about adult protection procedures. EVIDENCE: The home has a complaints procedure. Service users spoke about any areas of concern they had raised and how they had been responded to promptly. Copies of the complaints procedure in two other languages, in addition to English, were displayed in dining rooms. The complaints book was viewed. It is used to record all issues raised by relatives and service users. Follow up records indicated that these issues had been resolved. No formal complaints were received by the home since the last inspection. A more formalised complaints system is required in order to analyse issues and complaints raised. Staff have received training in adult protection procedures. From discussions with staff it was indicated they were knowledgeable and knew the appropriate action to take in the event of suspicion of abuse or neglect. The home has a procedure in place for responding to allegations of abuse. Aashna House G52-G02 S22715 Aashna House V222790 230505 Stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 20 21 24 25 26 The home is pleasantly furnished and comfortable. The comfort and safety of individuals has been compromised somewhat by the failure of the organisation to respond promptly to urgent repairs. EVIDENCE: The premises are well designed and purpose built as a care home. It is conveniently located in a quiet close with enclosed well-maintained gardens. Gardens are accessible to wheelchair users and offer solace with an abundance of fragrant flowers. A large part of the planned maintenance programme had been completed, although it was not completed within agreed timescales. Since the last inspection the home has continued with a decorating programme and a number of bedrooms were decorated. Decoration to dining rooms and other bedrooms have not been completed. There have been problems with the heating and hot water system for a number of months. Two new boilers were fitted but these were not operating efficiently on inspection day. A new valve had been ordered to correct the faults. Some service users on one side of the Aashna House G52-G02 S22715 Aashna House V222790 230505 Stage 4.doc Version 1.30 Page 17 building had been affected and were without hot water in the washbasins and showers. Provision had been made to supply hot water in bowls to those service users affected. The inspector received confirmation that the repair had been completed within a week of the inspection. Equipment is serviced regularly at the home but the organisation has been very slow generally to respond to urgent repairs such as the boiler system. This must improve otherwise consideration could be given to enforcement action. Individual bedrooms viewed were comfortable and pleasant. Service users had personalised them with statues and pictures. The premises throughout were clean and odour free. Showers and kitchens were clean. It was reported by one service user that mice had been seen at the home. The inspector received a certificate confirming that a pest control company had carried out the necessary action. The home has experienced problems with ants and vermin in the past and should have a routine pest control contract in operation. Aashna House G52-G02 S22715 Aashna House V222790 230505 Stage 4.doc Version 1.30 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 28 29 30 Staff are competent and motivated to provide a good quality of care but they require further development and training. EVIDENCE: The staff team reflect the cultural diversity and ethnic origin of service users. Sufficient numbers of staff are deployed daily to meet the needs of people living at the home. Records viewed and completed by the manager indicated that all staff checks were completed before appointed to post. Records viewed confirmed that staff had been provided with a variety of training in the past year. However as English is not the first language for the majority of carers no follow up was made following training to check individuals understanding of the training or monitor if it had been effective in developing skills. The manager is exploring all the training available that will meet the needs of the staff team. There is an induction training provided by the organisation, but this relates to generic housing issues. The home does not have an induction training and foundation programme that meets National Training Organisation specification, or that includes training on the principles of care, safe working practices, the experiences and particular needs of the service user group. The registered provider must ensure that the care home is conducted so that staff are sufficiently trained to make proper provision for the health and welfare of service users. Although this was the subject of a requirement in the previous inspection report more time is required to enable access to suitable training. A number of staff have commenced the NVQ programme in care. The assessor Aashna House G52-G02 S22715 Aashna House V222790 230505 Stage 4.doc Version 1.30 Page 19 has not completed the work with staff and a new source of training is required to complete the programme. Service users spoken to said that staff were kind and thoughtful and that they worked hard and did a good job at making life pleasant for all at the home. One relative commented that his mother had lived at the home for some time and that he had been very pleased with the care given to her. Aashna House G52-G02 S22715 Aashna House V222790 230505 Stage 4.doc Version 1.30 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 35 36 38 Improvements are required to staff supervision in order to provide a more informed and responsive service to service users. Service users money is properly looked after. EVIDENCE: The manager had recently returned from maternity leave. She had settled back well into her role and had already commenced working on developing the staff team. She spoke to the inspector of the difficulty finding appropriate trainers to suit the needs of the staff team. The application to register with CSCI as manager had not been completed. The organisation has not developed a quality assurance system. A number of methods are used to evaluate the service such as internal service user reviews, local authority reviews and unit meetings with service users and relatives. These initiatives need to be developed in order to evaluate fully how successful Aashna House G52-G02 S22715 Aashna House V222790 230505 Stage 4.doc Version 1.30 Page 21 the home is in meeting its aims and objectives and to assist with future planning and development. This requirement remains unmet from the previous inspection. Safeguards are in place at the home to protect service user’s financial interests. The administrator maintains accurate up to date records of all financial transactions. Individual bank accounts are held in safekeeping at the office for service users. Copies of Regulation 26 visits to the home have been completed but these have not been always been submitted for the past month to CSCI. A number of records relating to the maintenance of the building were viewed. Records indicated that weekly fire alarms were tested and that regular fire drills were conducted. Regular servicing had also taken place for electrical and hot water systems. Records viewed indicated that service users experienced a very small number of accidents. Staffs spoken to said that they were supervised directly by senior care workers and team leaders on the units. This was evident in direct observations made at the home by the inspector. No formal one to one supervision is undertaken with staff. This remains the subject of a requirement. The home has worked hard on recruitment and the provision of staff that can communicate effectively with service users. Training records indicated that staff have recently received a variety of training, these included first aid, food and hygiene and moving and handling people safely. Aashna House G52-G02 S22715 Aashna House V222790 230505 Stage 4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 1 3 1 x 3 2 2 3 STAFFING Standard No Score 27 x 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 2 x x x 2 2 x 2 Aashna House G52-G02 S22715 Aashna House V222790 230505 Stage 4.doc Version 1.30 Page 23 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 1 Regulation 5 (1) Requirement The registered person must ensure that a service users guide is produced in languages understood by people living at the home. The registered person must ensure that staff are trained and competent in checking blood sugars in emergencies. The registered person must ensure that advice and instructions given by district nurses, GP and consultants is recorded in service users plans of care and followed. Improvements are required in the working relationships with district nurses as service users depend on care staff to interpet and communicate on their behalf. The registered person must ensure that a risk assessment is undertaken for any service user who takes responsibility for administering his/her own medication. The registered person must ensure that all service users are provided with hot water supply in wash basins and showers, and Timescale for action 30 August 2005 2. 8 12 (1) (a) 18 (1) (c) (1) 13 (1) (b) 30 August 2005 30 July 2005 3. 78 4. 9 12 (2), 13 (2) & 13 (4) (c) 30 August 2005 5. 19 21 23 (2) (j) 30 May 2005 Aashna House G52-G02 S22715 Aashna House V222790 230505 Stage 4.doc Version 1.30 Page 24 6. 19. 20. 24 7. 30. 36. 38 8. 28 9. 31 10. 31 11. 33 that urgent action is taken to respond to repairs( Completed within 7 days of the inspection.) 23 (2) (b) The registered person must ensure that a programme of routine maintenance and renewal of the fabric and decoration of the home is produced and implemented with records kept. This is to include the dining rooms and all bedrooms identified as requiring it. (Previous timescales of 28/02/05 not met) 12 (1) (a) The registered person must & (b) & 18 ensure that there is a staff (1) (b) (i) training and development programme including induction and foundation training, which meets NTO workforce training targets and is tailored to the needs of the staff team including presentation in suitable formats for staff.(Previous timescale of 31/03/2005 not met) 18 (1) (b) The registered person must (i) ensure that a minimum of 50 care staff acquire NVQ level 2 in care by December 2005. 8&9 The resgistered person must ensure that the application for registration of manager takes place. Original timescale of 30/04/05 extended to allow for absence of the manager. 10 (3) The registered person must ensure that the manager receives training for the role and responsibilities of the care home manager and the conditions affecting older people.(Timescale of 30/04/05 extended to allow for absence of the manager due to maternity leave) 24 The registered person must ensure that an effective quality assurance system is put in place G52-G02 S22715 Aashna House V222790 230505 Stage 4.doc 30 August 2005 30 August 2005 31 December 2005 30 July 2005 30 September 2005 30 September 2005 Page 25 Aashna House Version 1.30 12. 36 18 (2) 13. 35 26 (5) (a) to ensure that the home is successful in meeting its aims and objectives.(Previous timescale of 30/11/04 not met). The registered person must ensure that all staff at the home receive regular formal one to one supervision six times a year. (Previous requirement partly met. New timescale set for one to one supervision The registered person must ensure that copies of Regulation 26 visits are forwarded to the CSCI every month 30 July 2005 30 July 2005 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 7 12 Good Practice Recommendations The registered person should ensure that staff include as much information as is possible on daily records maintained for service users The registered person following consultation with service users consider developing further activities that are stimulating and fulfilling and that match individuals changing needs and capacities. The registered person should ensure that service users are consulted on personal likes and dislikes of food and of all changes to menus. The registered person should ensure that an annual contract is operated with a pest control company 3. 4. 5. 15 26 Aashna House G52-G02 S22715 Aashna House V222790 230505 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection SE London Area Office Ground Floor, 46 Loman Street Southwark London SE1 0EH 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 Aashna House G52-G02 S22715 Aashna House V222790 230505 Stage 4.doc Version 1.30 Page 27 - 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. 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