Inspection on 28/07/06 for Ascot House

This inspection was carried out on 28th July 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ascot House 19/01/06

Ascot House 05/09/05

Ascot House 25/01/05

Ascot House 28/04/04

Ascot House 11/11/03

Similar services:

Chirnside House

Sunny Bank (P.R.S.) Ltd

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Ashwood Court Unit 1

Langrigg House

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

CARE HOMES FOR OLDER PEOPLE Ascot House Ascot Avenue Sale Cheshire M33 4GT Lead Inspector Joe Kenny Key Unannounced Inspection 28th July 2006 10:15 X10015.doc Version 1.40 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 Ascot House DS0000032526.V305724.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Ascot House DS0000032526.V305724.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ascot House Address Ascot Avenue Sale Cheshire M33 4GT 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) 0161 912 1212 0161 973 6780 Trafford Metropolitan Borough Council Mrs Carol Barber Care Home 45 Category(ies) of Dementia - over 65 years of age (0), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (0), Old age, not falling within any other category (0) Ascot House DS0000032526.V305724.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home provides accommodation for a maximum of 45 service users, 17 of whom require care by reason of old age (OP), 19 of whom are older people who require care by reason of dementia (DE(E)) and 9 of whom are older people who require care by reason of their mental ill health (MD(E)). Separate lounge and dining space is provided to meet the needs of the service users who require care by reason of dementia (DE(E)) and the needs of the service users who require care by reason of their mental ill health (MD(E)) There are currently 3 additional named older service users who require care by reason of old age (OP) and 2 additional named older service users who require care by reason of dementia (DE(E)). Should any of these service users no longer require accommodation at the home, the places will revert to the category (MD(E)). The Statement of Purpose must be maintained in line with the requirements of Schedule 1 of Regulation 4 (1) of the Care Homes Regulations. The Statement must be kept under review and updated. Any changes to the homes purpose must be agreed with the Commission for Social Care Inspection prior to implementation . The staffing arrangements at the home must be maintained in line with the minimum levels set out in the guidance published by the Residential Forum, `Care Staffing in Care Homes for Older People`. This must be reflected in the Statement of Purpose. The home must be managed at all times in accordance with the guidance and regulations issued in respect of older peoples` homes by the Secretary of State for Health under Sections 22 and 23 (1) of the Care Standards Act 2000. The authority must at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 19th January 2006 2. 3. 4. 5. 6. Date of last inspection Brief Description of the Service: Ascot House is a purpose built local authority residential home, which provides accommodation and personal care to 45 older people. The home is located in a residential area on Ascot Avenue, off Manor Avenue, Sale, Cheshire. The home is close to public shops and transport routes into Sale and Altrincham. The home is divided into 5 units, 2 of which accommodate 18 older people, 2 of which accommodate older people with dementia and 1 of which accommodates Ascot House DS0000032526.V305724.R01.S.doc Version 5.2 Page 5 older people with mental ill health. Each of the 5 units has its own lounge/dining area and kitchenette. Bedrooms are located close off communal areas and easily accessed by service users in each unit. Accommodation is provided in 45 single rooms. Forty-three of the 45 single bedrooms are over 12 sq. meters and could therefore accommodate wheelchair users. The remaining 2 bedrooms measure in excess of 10 sq meters. The weekly fees are £380.29. Ascot House DS0000032526.V305724.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out unannounced and took place on the 28 July 2006. The inspection findings are based on information received from the home in the form of a pre inspection questionnaire and comment cards/ quality assurance survey received from residents or their representative as part of the inspection process. A total of eleven residents’ comment cards and twelve relatives’ comment cards were returned to the Commission. Information received from the home since the last inspection was also used as part of the inspection process. The manager of the home was on leave at the time of the inspection and the visit was conducted by the Service Manager and senior staff on duty at the time of the visit. The inspection visit included discussions with management staff, care staff and residents living in the home. A tour of the building was undertaken and records relation to care plans, staff and resident’s files, health and safety records and staff rotas. What the service does well: The lay out of the home enables the service to respond to the identified needs of residents living in each of the designated units of the home. The staffing arrangements ensure members of staff are assigned to each of the five separate units. The plans of care identified and responded to the diverse primary care needs of residents accommodated in each of the units. Progress on developing and monitoring the content of resident’s records is regularly undertaken through review and monthly internal monitoring visits. The home was well maintained with programmes of development and decoration identified and scheduled for the future, following a rewiring of the fire system in the home. Comments received from relatives and residents who returned comment cards were positive about staff, the home and care provided. The Regulation 26 visit reports in respect of the home demonstrate a representative of the Local Authority on a monthly basis carries out regular, comprehensive audits of the conduct of the home. Ascot House DS0000032526.V305724.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: 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. Ascot House DS0000032526.V305724.R01.S.doc Version 5.2 Page 8 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 Outcomes Statutory Requirements Identified During the Inspection Ascot House DS0000032526.V305724.R01.S.doc Version 5.2 Page 9 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 the following standard(s): 1, 2, 3, 5 and Standard 6 does not apply Quality of this outcome area is good. This judgement has been made using available evidence and a visit to the service. The Service Users guide and other information leaflets contained information about the home and services offered. The assessment and admission process informs the prospective resident and the relatives as to whether the home is able to meet their needs and wishes. EVIDENCE: At the time of inspection there were 38 residents accommodated. Each service user is provided with a Service Users guide containing information about the services to be provided by the home. Other informative leaflets are available about the home and are offered to persons enquiring about the home or when moving into the home. Ascot House DS0000032526.V305724.R01.S.doc Version 5.2 Page 10 A number of new admissions had taken place since the last inspection and included residents moving from another home managed by the Local Authority which had voluntarily closed. The service manger stated that residents and relatives had been consulted and involved in the move to Ascot House, and where possible visited the home prior to the move. A number of staff also transferred at the same time and this offered residents some consistency in care and contact with staff known to them. Information provided to residents ensured they had the necessary information to make a choice as to where they lived. Ascot House DS0000032526.V305724.R01.S.doc Version 5.2 Page 11 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 the following standard(s): 7, 8, 9 and 10. Quality of this outcome area is good. This judgement has been made using available evidence and a visit to the service. The records relating to health and personal care indicated that staff are meeting the residents’ assessed needs. EVIDENCE: The home had addressed issues relating to monitoring of specific health care needs such as monitoring of weight on care plans and provision of regular bathing arrangements. This was identified on the last inspection and a requirement was made about consistently recording information where there was an identified risk relating to health and personal care. The home has established systems to ensure this information is being recorded so as to inform the home of any changes in health care needs of residents. Reviews of care are carried out monthly and on a three monthly basis meetings are held with residents to get their views about the service they receive. Ascot House DS0000032526.V305724.R01.S.doc Version 5.2 Page 12 On checking the daily records, some were noted to have lengthy gaps between daily recordings (8-11 days). Senior staff are advised to monitor such gaps and discuss issues with the nominated key worker. The care plans further demonstrated that changes to the care plan were dated and signed by the person reviewing of making any amendments on care plan. Seven designated staff administer medication. Procedures for administering are clear and medication is stored and administered from a number of secure areas located close to communal areas. The storage areas and records for the medication administered from each area were examined. The storage areas were found to be clean, orderly and well managed. There were appropriate arrangements for recording medication received by the home and medication returned for disposal. Insulin (Lantus)was being administered to a resident from medication prescribed to a named resident no longer at the home. All medication must be prescribed by the person’s GP. The medication administration records were examined and evidence that records were being signed consistently. There was evidence on files of visits by health care professionals such as general practitioners, optician, and district nurses where a resident had been referred for treatment. Staff were observed to support residents in a friendly and supportive manner and were observed to engage in conversations with residents. A nominated key worker is assigned to support named residents to ensure care needs are being met, supports residents. Each key worker is supported by a nominated senior carer. The senior carer is seen as the direct link between carers and the manager and is involved in reviewing care plans and developing risk assessments in consultation with the carer and resident where possible. Relatives responding through questionnaires, used as part of the inspection, commented that they were ‘more than pleased with the care provided’, ‘lovely home’, ‘privacy and dignity is respected’ and ‘ staff very caring’. Some relatives did comment that they would like to be more involved in ‘making decisions about care’. The home is advised to consult with all relatives relating to this process especially through reviews. Ascot House DS0000032526.V305724.R01.S.doc Version 5.2 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 the following standard(s): 12, 13, 14 and 15 Quality of this outcome area is good. This judgement has been made using available evidence and a visit to the service. Daily arrangements in the home enabled residents to plan how they spend their day, maintain contact with family and local community and respected their social, religious, dietary and personal preferences. EVIDENCE: Residents stated that they were free to arrange how they spent their day, when they retired for the night and what time they got up. Programmes of activities are structured and organised by students from Trafford College. However, students were on their summer break and not available to organise such activities during the summer period. The absence of structured activities may be the basis for comments by residents on the lack of suitable activities at the time they completed the comment cards. The arrangement of sustainable structured activities should be addressed by the home. Ascot House DS0000032526.V305724.R01.S.doc Version 5.2 Page 14 Residents were observed to be relaxed and enjoying music tapes indoors whilst others accessed the outdoor secure areas to enjoy the fine weather being experienced in July. A member of staff is assigned to each of the units and staff were observed to interact well with resident and ensured residents had access to drinks during this hot period of weather. A senior is available to support staff in delivery of care to each of the units. There was evidence of a range of indoor activities and board games. Activities can be held in small groups or in the larger lounge to the left of the main entrance. A number of relatives who completed the comment cards and quality audit surveys indicated that they were happy with social and cultural/religious arrangements offered to residents. Meal arrangements are planned using seasonal, four weekly rotating menu plans. Each scheduled menu offers an alternative to residents and includes specialist menus for residents who require diabetic and low fat diets. The last recorded records of choices offered ceased on 18 July 2006. The home is advised to commence this record to further evidence choices taken up by residents. The cook confirmed she is informed of needs of residents coming to the home for respite care. The home had proactively address comments by resident and staff in relation to meal presentations and preparation. It was encouraging to note that the action taken by the home had improved meal arrangements. A member of staff is being put forward to be an approved driver for the home in order to plan some trips out using a minibus provided by the transport section of the Local Authority. Ascot House DS0000032526.V305724.R01.S.doc Version 5.2 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 the following standard(s): 16 and 18 Quality of this outcome area is good. This judgement has been made using available evidence and a visit to the service. Residents and relatives had access to a clear complaints procedure. Programmes of training in adult abuse awareness for staff and compliance to Local Authority procedures protected residents. EVIDENCE: The home had taken action to address provision of training in dealing with complaints and responding to complainants. The home had a complaints register and recorded how complaints were investigated and recorded the outcome. One complaint had been dealt with through the homes internal procedures. The information relating to the complaint indicated it had been upheld and appropriate action taken to address the concern raised. Three relatives commented that they were not aware of the homes complaints procedure. The home is advised to be proactive in bringing this procedure to the attention of all relatives. The home was advised to record all concerns raised such as those relating to meal arrangements. It was evident the home had taken appropriate action to address the concern but had not recorded the issue through the complaints concerns procedure. Ascot House DS0000032526.V305724.R01.S.doc Version 5.2 Page 16 The home had also commenced a programme of training in adult abuse awareness for all staff. Training had been provided to all staff and they had received a certificate to confirm their attendance on the course. Staff have also signed a tracking sheet confirming they have read Trafford local authority guidelines on adult protection and whistle blowing procedures. Ascot House DS0000032526.V305724.R01.S.doc Version 5.2 Page 17 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 the following standard(s): 19, 20, 22, 24,25 and 26 Quality of this outcome area is good. This judgement has been made using available evidence and a visit to the service. Overall, the home was clean, tidy and comfortable, with a good standard of furnishings and fittings. EVIDENCE: The home is located in secure grounds which offer residents accessible secure out door facilities. There is designated car parking space and the home is easily accessed on the one level with no steps to negotiate. The home does offer residents a designated smoking area; this information is detailed in information about the home. The interior is spacious and from the main foyer it is easy to access the small designated units where residents communal and individual bedrooms are located. Ascot House DS0000032526.V305724.R01.S.doc Version 5.2 Page 18 A programme of rewiring and renewal of the fire system had been undertaken since the last inspection. This work had up graded detection and fire safety arrangements for the home. A programme of redecorating was due to start in the weeks following this inspection. There was a good standard of furnishings and fittings in the home in general and each unit appeared clean and comfortable. Staff confirmed that issues relating to layout of furniture in lounges was being monitored to ensure residents were not at risk of obstruction or falling. This was an issue identified on a previous inspection. Maintenance and up keep of the home is monitored and sustained by the designated housekeeper and team of ancillary staff. The housekeeper spoke about her role in monitoring cleaning and maintenance issues in the home and stated that systems used by the home were effective. Observations on touring the home supported comments by this member of staff. Programmes of renewing rotted wooden window frames had started and were being replaced with double glazed PVC windows. Work was being carried out to renew some damaged frames at the time of this visit. On touring the building there was evidence the home accessed and provided equipment for staff when assisting residents to maintain their safety when mobilising and transferring. The emergency call system was tested in one bedroom and the response time taken by staff was not effective. This issue must be monitored by the home to ensure residents are safe. Bedrooms were clean bright and reflected diverse interests and personal belongings of individuals. On touring the home a number of facilities were locked using a ‘star’ lock device. This style is not appropriate and a more appropriate lock must be fitted. On the West upper wing the privacy lock on one of the toilet facilities was not function and must be repaired. Ascot House DS0000032526.V305724.R01.S.doc Version 5.2 Page 19 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28, 29, and 30 Quality of this outcome area is good. This judgement has been made using available evidence and a visit to the service. The recruitment practices, training and supervision procedures introduced by the home, protected residents from risk of harm or poor practice. EVIDENCE: A new manager had been appointed to the home, and had been registered with the Commission. Comments by relatives acting on behalf of residents commented on the positive impact she had on the management of the service since her appointment. Recruitment and selection procedures had been reviewed by the home to address identified shortfalls following the last inspection. Although there was a temporary embargo on recruitment of new staff, the procedures to be used by the home addressed a full audit of applications to ensure information required to determine an applicant’s suitability was received and include comprehensive reference and POVA checks. A number of staff have been redeployed to Ascot House from one home which closed in July 2007. Ascot House DS0000032526.V305724.R01.S.doc Version 5.2 Page 20 The staffing hours for the period 23 to 29 July were assessed and indicated that 111 management hours were provided fro the week. There were 96 hour Senior care and the home operates with an assignment of 445.75 care hours. The arrangements for care hours in the night cover were appropriate to meeting the needs of residents. The manager is involved in the selection and interviewing of applicants and is also directly involved in carrying out Criminal Record and POVA first checks. Evidence of such checks is retained on staff files. The information relating to training provided to staff is held in a central record and demonstrated all staff received training ranging from induction, mandatory training and training specific to the service user group they supported. Training is discussed during supervision, as evidenced on documents seen and staff are informed of future training and are advised to put their name on notices relating to planned training. Training was planned in Cultural Awareness in response to the recommendation made at the last inspection. A total of 28 care staff are employed. The information relating to training in NVQ level 2 and above indicated that 14 staff had achieved or were in the process of achieving this award which represents a 50 ration of the staff team. The training information also indicated that eight staff held First Aid certificates. Programmes of supervision were being carried out but these should be a minimum of six sessions per year. Some files demonstrated short falls in supervision sessions whilst others were well maintained. The home is advised to develop a standard pro forma document for supervision topics. Ascot House DS0000032526.V305724.R01.S.doc Version 5.2 Page 21 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality of this outcome area is good. This judgement has been made using available evidence and a visit to the service. The management and administration arrangements for the home evidence that the home is being run in the best interest of residents their relatives and staff. EVIDENCE: The management arrangements for the effective running of the home are conducted in the best interest of residents. A new manager has recently been registered in respect of the home and internal audits on the conduct of the home are regularly carried out by a nominated manager for older people’s services. Ascot House DS0000032526.V305724.R01.S.doc Version 5.2 Page 22 The home holds regular meetings with relatives, the most recent held on 12 July 2006. Evidence of formal consultation with residents should be introduced to indicate that residents are consulted on all aspects of daily living in order to evidence their personal and health care needs are being met. A requirement was made at the previous inspection to the effect that the home must complete fire safety work highlighted at the homes last fire authority’s visit. This has been addressed. Procedures relating to monitoring of health and safety ensured residents were protected and that staff had the necessary support, supervision and training to carry out their duties. Staff had received updated training on health and safety working practices. A number of relatives also commented that they were not aware that they could access reports by the Commission following inspections of the home. Reports should be made available to the public. Tests and checks on the fire systems are carried out however checks on fire doors are carried out monthly and should be weekly. The last fire drill was carried out on the 19 June 2006. Ascot House DS0000032526.V305724.R01.S.doc Version 5.2 Page 23 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 X 2 3 2 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Ascot House DS0000032526.V305724.R01.S.doc Version 5.2 Page 24 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 OP9 Regulation 13 Requirement The home must ensure that all medication administered is in the name of the resident and prescribed by their general practitioner. The home must ensure all relatives are made aware of the of the homes complaints procedure. The home must monitor responses to the emergency call system to ensure residents are safe. The home must taken action to remove “star” lock device used to lock some facilities and also ensure all privacy function on toilet facilities. The home must review and develop their quality assurance system to provide a verifiable method, which involves residents, to audit the service and report on the findings. Tests and checks on the fire doors must be carried out on a weekly basis to ensure fire systems are effective. DS0000032526.V305724.R01.S.doc Timescale for action 22/09/06 2 OP16 22 22/09/06 3 OP22 13 22/09/06 4. OP24 23 22/09/06 5 OP33 24 22/09/06 6 OP38 13 22/09/06 Ascot House Version 5.2 Page 25 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 OP7 Good Practice Recommendations The home is advised to monitor lengthy gaps in daily progress sheets and to discuss issues with the nominated key worker. The arrangements relating to structured activities should be addressed by the home. The home was advised to record all concerns raised by residents to assist in the monitoring of the effectiveness of the service. The home is advised to develop a standard pro forma document for supervision topics and to ensure formal supervision occurs at least 6 times per year. Programmes of supervision must be sustained for all sections of staff team. 2 3 OP12 OP16 4 5 OP30 OP30 Ascot House DS0000032526.V305724.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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 Ascot House DS0000032526.V305724.R01.S.doc Version 5.2 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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