Inspection on 31/10/07 for Ascot House Care Home

This inspection was carried out on 31st October 2007.

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 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 Care Home 18/02/09

Ascot House Care Home 06/02/07

Ascot House Care Home 03/04/06

Ascot House Care Home 21/10/05

Ascot House Care Home 27/04/05

Ascot House Care Home 20/10/04

Ascot House Care Home 21/04/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Ascot House Care Home 34 Percival Road Sherwood Nottingham NG5 2EY Lead Inspector Lee West Unannounced Inspection 31st October 2007 11:00 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 Care Home DS0000002187.V351984.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 Care Home DS0000002187.V351984.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ascot House Care Home Address 34 Percival Road Sherwood Nottingham NG5 2EY 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) 0115 960 6506 PF 0115 960 6506 Mr William Scott Mr William Scott Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Ascot House Care Home DS0000002187.V351984.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. To be able to admit the named person of category DE(E) named in application V35244 dated 20/9/06 To be able to admit the named person of category DE(E) named in application No. V35244 dated 20/9/06. To be able to admit the named person of category DE(E) named in application no V35244 dated 20/9/06 The maximum number of persons the registered provider may accommodate in Ascot House is 20. The home may only accommodate male residents. Date of last inspection 6th February 2007 Brief Description of the Service: Owned and managed by Mr. W Scott, Ascot House, consists of 3 terraced houses joined together and situated in Sherwood, close to shops, pubs, post office and other local amenities. The home provides personal care and accommodation for 20 male older people. Accommodation includes 7 single bedrooms, with the remainder being double rooms, none of which have en-suite facilities. All bedrooms are located on 2 floors, staircases are steep, but there is a stairlift enabling people with mobility difficulties to gain access to the upstairs rooms. There is an enclosed garden area to the rear of the home and on street parking to the front. The fees are currently £298.21 to £323.36 per week, dependent on the care needs of service users, and includes general toiletries, but not the cost of hairdressing or chiropody. Ascot House Care Home DS0000002187.V351984.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This inspection was unannounced and involved one inspector and an “expert by experience.” The role of the ‘expert by experience’ is to talk with residents. The ‘expert’ is arranged through the charity Help the Aged. An ‘expert by experience’ means they have experience and skills to be able to speak with residents at an inspection. Their experience could be from previous work or they may have used care services themselves. The ‘expert by experience’ spoke with two residents, two members of staff, a visiting Community Psychiatric Nurse, and was given a tour of the building by Mr. Scott. The main method of inspection used is “case tracking”, which involves selecting three residents and looking at the quality of the care they receive by speaking with them, observation, reading their records, and asking staff about their needs. Four members of staff and three residents were spoken with, in addition to those spoken to by the expert by experience. Documents, including care plans, medication administration records and financial records were inspected to help form an opinion about the health, safety and welfare of residents at the home Responses from four residents’ surveys sent to the residents before the inspection visit, and information received by the Commission about the home, since the last inspection, were also considered, and helped to decide which areas to focus on. At the time of this inspection, the registered manager had not completed the Annual Quality Assurance Assessment, but the Commission received this on the 12th November 2007 and some information it contained has been used within this report. Ascot House Care Home DS0000002187.V351984.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? There has been some improvement in the care planning documentation and these now contain specific actions to assist residents, and include personal preferences such as where they want to eat, in their room or in the dining area. New chairs have been bought for the lounge area and one bedroom has had a new bed purchased and been redecorated. Communal areas are being redecorated and maintenance carried out. The middle lounge was being redecorated. Roofing has been repaired and the shower area is now waiting to be redecorated. Medication administration has improved and the practice of taking tablets from other people’s pack has ceased and an audit by the pharmacist was positive. Ascot House Care Home DS0000002187.V351984.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Ascot House Care Home DS0000002187.V351984.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 Care Home DS0000002187.V351984.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 6, Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. New service users have a thorough pre-admission assessment. A service user guide, with statement of purpose provides information needed to encourage potential residents to make an informed choice about entering the home and whether their needs will be met by the home. There are no service users admitted to Ascot House for intermediate care. EVIDENCE: The service user guide contained information that would help a person to make a choice about whether Ascot House could meet their needs. Pre-admission assessments were seen in the case tracked residents’ care plans, with care needs identified. Ascot House Care Home DS0000002187.V351984.R01.S.doc Version 5.2 Page 10 Residents spoken with said they had been given information about the home before moving in, and they were satisfied the staff meet their needs. Ascot House Care Home DS0000002187.V351984.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11, Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. To help them feel safe and confident their needs are met, residents have their needs set out in individual plans and they are treated with respect. Attention has been paid to their wishes at the time of their death. EVIDENCE: Care planning documentation now contains specific actions to assist residents, and include personal preferences such as where they want to eat, in their room or in the dining area. Care plans also contained evidence of visits by and to other professionals and also daily communication sheets. One of the residents spoken with said he was only able to move short distances with the use of a walking frame and needed help with washing and showering and that he was satisfied with the help he received. Ascot House Care Home DS0000002187.V351984.R01.S.doc Version 5.2 Page 12 During lunch and tea, residents were observed being offered assistance and encouragement to eat. Medication administration was observed to be fully supervised, and storage and recording of medication administration was accurate. At present no residents are responsible for their own medication, but there is a policy in place to enable this to be undertaken. Interactions between staff and residents were cheerful and spontaneous and the well-being of those who chose not to communicate, was observed and staff were treating them in a supportive manner, which maintained their dignity. Staff spoken with said the residents had, “very few relatives and they look upon us as their family, so it’s important to treat them well.” Care plans identified the residents’ personal preferences about their deaths, one resident who recently died was a non-believer and arrangements were made for a non-religious service. Another wished “to be in my suit with a packet of cigarettes in my pocket.” One health-care professional who was visiting two residents spoke about the home. Saying, “Residents rule the roost here,” “I can’t speak too highly of the care received by service users.” The residents being visited had been at Ascot House for a number of years and couldn’t have been looked after better. However, “the home could be better decorated and furnished, but Mr. Scott and the staff care about their residents.” Ascot House Care Home DS0000002187.V351984.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. There are no organised activities to help maintain mental capabilities, with many residents spending the day alone in their room, but Care plans identify religious interests. Visitors are welcomed, and, for those who can mobilise independently, contact with the local community is encouraged. Food at the home is basic, but served in sufficient quantities for residents. EVIDENCE: One resident spoken with said he spent most of his days “watching telly.” And watched daytime television. He also said he was unable to go outside the home now, because he had to use a walking aid, which restricted his “going out a lot. I can’t remember the last time I went out of this building.” Some residents said they preferred being alone, but others said the days were “very long and lonely, with not much to do.” Another said, “there has never been anything like trips out since I’ve been here and I’d love to go out.” Ascot House Care Home DS0000002187.V351984.R01.S.doc Version 5.2 Page 14 Another resident said he sometimes went out for lunch to a local pub. He also said that newspapers were available, “if you went out and got your own, or someone went to the shop.” Responses to the surveys sent to the residents all said there were no organised activities and that they spent a large part of their time alone in their rooms. Residents and staff said visitors were always welcome, but didn’t come very often. Today’s lunch was a mixed grill, which residents said was the “Wednesday special.” There was no choice today, except in the ingredients each person wanted. The food was basic, well cooked, in a clean kitchen and served to residents in the dining area, or on trays and taken to their room. Residents spoken with said the food was “Iffy, good in quantity but quality wasn’t brilliant.” Another said, he had porridge for breakfast, which was enjoyed, but the food was “pretty standard, but there is always a choice.” Residents who responded to the survey also said the food was “basic, but there was always plenty to eat and choices.” The cook was spoken with and confirmed Wednesday was a special “fry-up day” because this is what they wanted, and they can choose their ingredients. A member of staff said she sometimes played cards and dominoes with residents and sometimes she took a resident for short walks to nearby shops, or just to sit on a wall and watch the traffic. She also said her normal caring duties left little time to oversee activities. After lunch residents were observed in the lounge areas, some were asleep in front of the television, but some were walking around the home interacting with staff. However, there were no structured, regular, activities, and in particular, nothing to stimulate mental capacity. During the afternoon though, the home was being decorated to celebrate “Halloween” with staff dressing up as witches and some residents joining in. The tea was prepared with “Halloween foods”. Ascot House Care Home DS0000002187.V351984.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are dealt with, but not in accordance with the home’s complaints procedure. Residents are protected by staff who are aware of their role in safeguarding adults procedures. EVIDENCE: There were no complaints recorded at the home, but the Commission’s records contained a recent complaint from a healthcare professional. During discussions with Mr Scott and the deputy and a tour of the shower area, it was evidenced the contents of the complaint, which was the poor state of the shower room, had been dealt with. However, the home’s complaints procedure had not been followed, as no-one had written to the complainant and there was no record in the home of the complaint, or its outcome. Responses in the resident surveys said any complaints were usually dealt with and residents spoken with said they generally didn’t have any complaints. There was no evidence in the staff files of staff having undergone training in safeguarding adults’ issues, but on speaking with staff, they said they had recently attended with staff from the other home. Discussion about their roles showed they were aware of what they must do to protect residents and staff. Residents spoken with said they felt secure with staff. Ascot House Care Home DS0000002187.V351984.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 23, 25, 26, Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. There have been some improvements in the décor and maintenance of the home, but there are still large areas requiring attention to ensure the home is safe and comfortable for residents. EVIDENCE: Although recently decorated, corridors within the home still require attention, particularly to the carpets, which were soiled. The back corridor to the laundry area and staff toilet was poorly decorated, with holes in the plaster on the walls. The downstairs shower room floor had been repaired, but there was still some black mould on the ceiling, although there was an area where some had been removed. The room was warm and clean, but like other areas, in need of decoration. Ascot House Care Home DS0000002187.V351984.R01.S.doc Version 5.2 Page 17 The middle lounge had new armchairs and was being decorated during this visit, and the hallway and staircase opposite the main entrance had been decorated. One double bedroom had been completely redecorated, with a new bed, but the wardrobe was in need of repair as the mirror was broken. This room was in stark contrast with other bedrooms, which were badly in need of maintenance, redecoration and replacement bed linen. Bed linen in the occupied rooms was clean, but showed signs of extensive wear, with pillows that were, “lumpy and uncomfortable,” commented one resident. Residents spoken with said they were satisfied with the home and their personal rooms, but they also said there was a lot of maintenance needed to window frames and some roof areas where damp was coming through. Responses in the resident surveys also reflected this, also commenting that the carpets in the home “could do with a shampoo,” and “my room’s ok.” The kitchen was clean and hygienic with all floors and surfaces clean and uncluttered. The garden area was reasonably tidy, with some tired looking garden furniture. Sheets were blowing on the line across the garden, and a resident was observed helping the carer to put them out, and take them in later. Staff said this was a task he enjoyed carrying out and it helped them. Ascot House Care Home DS0000002187.V351984.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30, Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The numbers of staff generally meet the needs of the residents, and there is a commitment towards staff training, although there remain some shortfalls. Recruitment practices require more improvement to provide protection and competent workers for support and assistance of residents. EVIDENCE: The duty rota reflected the number of carers working during this visit and Mr. Scott was also on the premises, Staff records case tracked contained Criminal Records Bureau checks, but none contained any photographs, or other forms of identification. There were no job descriptions in the files and also no contracts or terms and conditions. Staff spoken with all said they had not had a contract of employment, or terms and conditions and that Mr. Scott told them their roles and responsibilities. They said that as they had been working at the home for a long time, they knew the routines well and how the residents liked things. There was no evidence of who carried out the interview process, responses to any questions, or any indication of previous work experience on the files, and Ascot House Care Home DS0000002187.V351984.R01.S.doc Version 5.2 Page 19 application forms did not contain questions to enable carers to declare their experience and background. One staff file contained only one professional reference, and one contained a reference, which did not identify the sender. Staff files contained certificates of training, but moving and handling training was out of date in all those case tracked. There was also no evidence of safeguarding adults training, but on discussion with the staff one carer said she had recently been on a safeguarding adults training session, with the staff from the other home owned by Mr. Scott. The cook, who carries out the sleepover duty on a regular basis, had not had any first aid, moving and handling, or safeguarding adults training. Although the duty rota showed staff working with him had received some training, but moving and handling had not been updated, leaving staff and residents vulnerable during the nights. Residents spoken with said they were happy with the staff and they were available whenever they were needed. They also said they felt safe and one said that they felt “everyone tries their best for me.” Five of the eight staff members have achieved National Vocational Qualifications in Care at level 2, with three working towards the qualification. One new staff member said she had had an induction and records had been signed to evidence this, but this was not recorded in the staff file. On discussion she was able to describe the elements of the induction programme and her role and responsibilities. Ascot House Care Home DS0000002187.V351984.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37, 38, Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The registered manager relies on the deputy and administrator to carry out day to day running of the home, but as he is counted in the numbers on the duty rota, this leaves the staffing levels low, to meet the needs of the residents at times when demand for support and help is at its highest. EVIDENCE: The manager is often out of the home, which leaves the day to day running to the deputy, who is then unable to assist the care staff carry out the care requirements for residents. The Annual Quality Assessment report states twelve residents require assistance with dressing and undressing, whilst all need support with washing Ascot House Care Home DS0000002187.V351984.R01.S.doc Version 5.2 Page 21 and bathing. As the registered manager is counted in the staffing numbers on the duty rota, this has a cascade effect and reduces the number of people available to help residents with their care needs. Staff spoken with said they were sometimes short of staff, particularly when the deputy was, “dealing with the paperwork.” The Annual Quality Assurance Assessment states roles and responsibilities will be more clearly defined, but does not detail how this should be done. Records, which the registered manager should maintain, were not complete. Recruitment documentation was incomplete, with no record of interview questions and responses, no health declaration, no proof of identification and when employed, no evidence of terms and conditions of employment, or induction. The Commission has not received notifications of incidents, or events, occurring within the home, in particular recording any deaths, admissions to hospital, or incidents between residents. The deputy and Mr. Scott confirmed none had been sent. There was no evidence of Mr. Scott working towards any management qualification, or having had any up-dating training recently, although he has stated he is enrolled on a course to undertake the National Vocational Qualification at Level 4. Residents’ financial records were inspected. These were found to be accurate, with receipts and signatures to enable them to be audited. Residents spoken with said they were given money each week, and if they wanted anything extra, it was always available. Staff also said Mr Scott would often pay for things “out of his own pocket” if necessary. Records of health and safety checks, including fire alarm testing, were seen, showing regular testing, with the appropriate dates and signatures. The Annual Quality Assurance Assessment also set out the dates of checks. The Annual Quality Assurance Assessment stated residents meetings were held and quality surveys completed. However, although there had been resident meetings in the past, these had not been held for some time, even though there was a notice displayed “residents meeting last Thursday every month.” There was also no evidence of any quality assurance reviews being carried out for some time. Residents and staff confirmed there had not been any meetings for some time, and residents said there had not been any questionnaires to complete. Ascot House Care Home DS0000002187.V351984.R01.S.doc Version 5.2 Page 22 Residents who responded to the surveys said they had not been involved in any quality surveys, or meetings, but that they would tell staff if they were not happy. Ascot House Care Home DS0000002187.V351984.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 X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X 2 x 2 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 x 3 x 2 2 Ascot House Care Home DS0000002187.V351984.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 OP12 Regulation 16(2)(n) Timescale for action You must consult residents about 31/01/08 their social interests and develop a programme for individual and group activities to support their needs for physical activity and mental stimulation, so residents well being can be improved and their mental and physical capabilities maintained, or improved. You must record all complaints 31/01/08 and follow the home’s complaints procedure, fully investigating any such complaint and also informing the complainant. So anyone who has a complaint has the opportunity to have the complaint taken seriously and dealt with. 28/02/08 You must ensure the home is in a good state of repair. Soiled carpets must be cleaned, damage from leaks put right, the broken wardrobe mirror in the refurbished double room replaced, worn bed linen and broken furniture in occupied bedrooms replaced and the current programme of redecoration, refurbishment and DS0000002187.V351984.R01.S.doc Version 5.2 Page 25 Requirement 2. OP16 22(3)(4) 3. OP19 23(2)bc Ascot House Care Home 4. OP29 19(1)b(i) 5. OP30 18(1) 6. OP31 9(1) 7. OP33 24(1) maintenance in all areas continued to provide a pleasant, clean and safe environment for the residents. You must obtain and keep on file two written references, proof of identity, including a photograph, birth certificate, passport, and documentary evidence of any qualifications to ensure all staff are eligible and competent to work at the home, to protect residents from harm. You must ensure training for all staff is kept up to date. Training must include staff who carry out sleepover duties, to make sure all staff are able to support care needs and protect residents at all times. You must provide evidence of working towards a qualification at level 4 National Vocational Qualification in management and care to demonstrate updating of skills, knowledge and competence in carrying out the role of registered manager, to enable you to provide a service which supports and protects residents and staff You must carry out effective quality monitoring, which could include re-establishing the resident surveys and residents’ meetings previously organised. After recording the information it would then enable you to review and improve the quality of care provided at the home for the residents. You must inform the Commission, without delay, of all deaths, admissions to hospital, accidents, injuries, or any incident which is detrimental to the health or welfare of a DS0000002187.V351984.R01.S.doc 30/12/07 31/01/08 31/01/08 31/01/08 8. OP38 37(1) 30/12/07 Ascot House Care Home Version 5.2 Page 26 resident, to enable the Commission to maintain up to date information of such incidents, and to enable you to monitor the standards of care, making any necessary changes to support and protect residents from harm. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ascot House Care Home DS0000002187.V351984.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Ascot House Care Home DS0000002187.V351984.R01.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. 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