Inspection on 09/06/06 for Ashcroft

This inspection was carried out on 9th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Ashcroft 28/06/07

Ashcroft 01/03/06

Ashcroft 26/05/05

Ashcroft 06/01/05

Ashcroft 23/06/04

Ashcroft 10/02/04

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

CARE HOMES FOR OLDER PEOPLE Ash Croft Halstead Road Eight Ash Green Colchester Essex CO6 3QH Lead Inspector Gaynor Elvin Final Unannounced Inspection 9th June 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 Ash Croft DS0000017750.V301969.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. Ash Croft DS0000017750.V301969.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ash Croft Address Halstead Road Eight Ash Green Colchester Essex CO6 3QH 01206 767367 01206 573970 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) Mrs Noeline Barbara Crowley Mrs Noeline Barbara Crowley Care Home 24 Category(ies) of Dementia - over 65 years of age (24) registration, with number of places Ash Croft DS0000017750.V301969.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st March 2006 Brief Description of the Service: Ash Croft is a family run home providing personal care for 24 older people with dementia. Owned and run by Mrs Crowley, and her family, the home has been open since 1986. A detached property, located in the village of Eight Ash Green, on the outskirts of Colchester, residential accommodation is all at ground floor level. There is a large communal lounge/dining area, 18 single rooms and 3 shared rooms. The home has a large secure garden to the rear of the property and ample parking to the front. The home has a Statement of Purpose providing information for prospective residents, which is available upon request. The current fee, confirmed at the time of inspection is £367 - £408 per week, reviewed annually. Hairdressing and chiropody services are provided at an additional cost. Ash Croft DS0000017750.V301969.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in June 2006, over two days for a total of eleven hours. All of the Key National Minimum Standards (NMS) for Older People and the intended outcomes were assessed in relation to this service during the inspection. The inspection process included discussion with the Registered Manager, the deputy manager, the senior carer, four care workers, the cook, three residents and one relative; examination of a sample of staff and residents records, supporting documentation and other records required to be kept in the home; direct and indirect observation. This report has been written using accumulated evidence gathered prior to and during the inspection. Due to cognitive impairment and disorientation to time and place discussion with the majority of residents with regard to care delivery was difficult, however observation of body language, expression and interaction between the residents and the staff, demonstrated that the residents were comfortable and relaxed at Ash Croft. Comment cards were left for residents’ families and representatives to complete, and any views expressed will be incorporated into the next inspection report. What the service does well: Ash Croft is a home that successfully provides a comfortable and friendly environment, which supports resident’s needs. The staff team, under the leadership of Mrs Crowley, delivers a good standard of care. The resident’s are relaxed and enjoy good relationships with the staff working at the home. The residents enjoyed the home cooking provided, which is of good quality and sufficient quantities. Personal and healthcare needs are treated promptly, sensitively and with respect. Relatives of those living at Ash Croft were encouraged to visit at any time and were warmly welcomed to the home. Those spoken with felt that any issues of concern would be listened to and acted upon. Ash Croft DS0000017750.V301969.R01.S.doc Version 5.2 Page 6 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. Ash Croft DS0000017750.V301969.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Ash Croft DS0000017750.V301969.R01.S.doc Version 5.2 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 the following standard(s): 1, 2, 3 & 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Prospective residents and their representatives were provided with the information they required to make an informed choice; and were provided with the opportunity to visit the home prior to making a decision about moving there. Not all service users had the benefit of an agreed signed and dated statement of terms and conditions identifying specific services and facilities available to them to meet their needs. A pre admission needs assessment was not carried out for all residents prior to admission. EVIDENCE: There had been no changes to the Statement of Purpose and Service Users Guide since the previous inspection and although these documents were not inspected on this occasion, they had been assessed as meeting the National Ash Croft DS0000017750.V301969.R01.S.doc Version 5.2 Page 9 Minimum Standards on previous inspections. The documents were made available to all prospective residents and their representatives. From the sample of residents’ files inspected, not all contained a signed copy of a Residential Contract and Agreement or Statement of Terms and Conditions. Those evident were generic and not appropriate to individual needs, identified services or personal fees. Some contracts were not signed and the Manager was advised to seek independent advocacy support for those residents with high cognitive needs and no immediate family. It is necessary to ensure that signed and dated copies of statement of terms and conditions/ residential contract and agreement are available in relation to each service user. From the sample of residents’ files inspected, the file of a recent admission indicated that no pre admission assessment had been carried out by the home nor had a needs assessment carried out by the social worker been received by the home prior to admission. There was little information gathered other than from the family and Social Worker by telephone, relating to the specific needs of the individual; and inform care planning arrangements. Ash Croft DS0000017750.V301969.R01.S.doc Version 5.2 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 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 the service. Care plans focused only on the main presenting needs and risks rather than adopting a person centred approach to the quality of their daily lives. Residents’ were looked after well in respect of their health and personal care needs. Policies and procedures for medication management were adhered to ensuring the safe administration of medication to residents. Personal care is offered to residents in a sensitive and unobtrusive manner, by staff that clearly understand and recognise their needs. Residents are assured that at the time of their death their needs and wishes are treated with sensitivity and respect. Ash Croft DS0000017750.V301969.R01.S.doc Version 5.2 Page 11 EVIDENCE: Care plans and health related risk assessments were generated from a computer software programme. The programme is generic and provides basic information to meet residents primary needs and did not reflect a person centred focus. The care plans required greater detail, particularly in relation to dementia care needs and should have contained better detail as to how care needs could be met. Cross-referencing information and care instructions from risk an assessment into the care planning process is poor, with limited reference to input from outside professionals. A greater focus on maintaining strengths and interests and meeting personal, social and emotional needs and objectives is required, recognising the need for regular review. Daily records and staff handover did not link to care plan objectives and focused mostly on eating and eliminating. Residents’ health needs are met appropriately and well monitored and prompt referrals are made to GP’s and relevant health professionals where required. Staff were observed to engage positively with each individual and demonstrated a good relationship with the residents they were supporting, treating them with dignity and respect. One relative spoken with explained he used to be the main carer for his wife before she came to Ash Croft and although she could not verbally communicate, she would cry if she was unhappy. He had not seen her cry during the time she was at Ash Croft and therefore he was assured she was being looked after well. The care plans identified medication prescribed, however it is recommended to ensure that information relating to the side effects and adverse reactions of medicines being taken by service users is readily available. The homes medicine administration system was inspected. This was a monitored dose system (MDS). Based upon the sample of records inspected the receipt, administration, storage, security and disposal of medication was found to meet National Minimum Standards. The senior carer, designated to take the lead on medication, demonstrated the procedures for dispensing medication and had a good understanding of medication administration and the need for six monthly reviews by the GP for those individuals on four medications or more, as required by the National Service Framework for Older People and Medication The home endeavours to offer a home for life to residents and provides palliative care to residents at the home, with the support of Community Healthcare professionals, for as long as their assessed needs can be met. An excellent detailed policy is available to guide staff in the care and support of Ash Croft DS0000017750.V301969.R01.S.doc Version 5.2 Page 12 residents in the last stages of illness. From conversations with management and staff, and information included in the notifications submitted to the Commission with regard to the death of residents, it was evident that the home responded appropriately to the changing needs of the residents and provided all the care and support they were able, in collaboration with the Primary Healthcare multi professional team. Ash Croft DS0000017750.V301969.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 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The provision of suitable activities to stimulate social and recreational interests for residents with dementia was adequate. Staff required further training in this area. Visiting arrangements are open and relaxed and family and friends links with the service were strongly encouraged and well developed. Meals provided in this home are of good quality, wholesome and freshly prepared; and mealtimes were a dignified social occasion. EVIDENCE: A fairly regular routine was kept to help residents remember what happens throughout the day. There were some good elements of practice, which included staff’s cheerful and positive attitude. Continual short interactions and constant verbal exchange was observed between staff and residents. Staff gave gentle reminders throughout the day of what was happening next, to give residents some conception of time. Ash Croft DS0000017750.V301969.R01.S.doc Version 5.2 Page 14 Each resident had varying cognitive and communication abilities; one resident spoken with experienced substantial difficulties in word finding. During a fifteen-minute conversation, three clear words provided a picture to the inspector about the previous lifestyle the resident had experienced, which was later confirmed from a written profile provided by the family. Unfortunately the profile was stored in a separate file in the deputy managers’ office and not included within the care plan. Not all residents had an ongoing or completed ‘life story’ or personal profile within their care plan enabling staff to understand the individual such as interests, experiences and lifestyle. The importance of addressing ‘life story’ work for residents, particularly those with dementia, must be given greater attention or other aspects of care delivery may be compromised. English is not the first language for many members of the care staff team. When asked how they manage difficulties they may experience in communicating with somebody who has high communication needs, one staff member said ‘we make time for the resident as each of us experience some communication difficulty at some time and patience and understanding is the key’. The staff agreed it is good to know the history of the person and the importance of talking to relatives. Residents are encouraged to make daily choices and maintain independence. This could be improved by exploring and introducing suitable methods of engagement and communication channels to provide opportunities for those individuals with high cognitive needs to express choice, such as picture books, particularly with regard to meals, past times and leisure interests. One resident was supported in maintaining and growing a vegetable plot. The home is looking to improve external communal areas reducing potential risks and enable the resident to go out unaccompanied. Hand eye coordination and physical movement is promoted through games such as skittles and large ball games. A session of music and movement was observed during the inspection. A volunteer activity coordinator, with the support of the deputy manager provides a range of activities one afternoon a week. These have included moulding with dough, cake making and reminiscence sessions. Further development is required to explore various approaches to appropriately engage residents in maintaining and stimulating social and recreational interests linked to the individual, particularly for those with high support needs. Daily records and staff handover did not demonstrate that staff are engaging residents in activities and identifying those interactions that, although are routinely carried out, form part of the occupational activities residents participate in an everyday part of life. Ash Croft DS0000017750.V301969.R01.S.doc Version 5.2 Page 15 The Manager and staff indicated that the service strongly encouraged family and friendship links and took a partnership approach with family members, which was paramount to caring for people with dementia. Relatives were observed to come and go throughout the inspection, signing the visitors’ book and having informal chats with the management and staff. Those spoken with confirmed that the staff were always welcoming and inclusive and there were no restrictions on visiting. Discussion with the homes’ cook, along with the examination of records indicated that a wholesome and balanced diet was provided for. The cook, through discussion with the resident or a trial and error basis, explored choice and individual preference. The main meal, on two occasions was observed to be a happy, social affair, conducted with dignity. The meal was taken leisurely and unhurried, staff were observed assisting residents with patience and dignity. On each occasion goodsized portions were provided and there was minimal waste. The service users spoken with said they enjoyed the food. Ash Croft DS0000017750.V301969.R01.S.doc Version 5.2 Page 16 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 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The complaints policy and procedure continues to meet the expectation of National Minimum Standards (NMS). The protection of vulnerable adults policy and procedure is unchanged and meets the expectations of NMS and local policy. EVIDENCE: The manager had an open door policy and residents and relatives were observed talking with her throughout the course of the day about general matters and any matters of concern to them. One relative spoken with confirmed that any issues of complaint or concern were listened to and dealt with promptly. The complaints log identified that the procedure was followed properly and recorded outcomes and actions taken to improve practice. The deputy manager indicated that many concerns by relatives were raised from gaps in their understanding and knowledge of dementia. The home is looking to form a relative support group to bridge this gap. Ash Croft DS0000017750.V301969.R01.S.doc Version 5.2 Page 17 Records relating to money held on behalf of residents were satisfactory at the last inspection. They demonstrated that the financial interests of those living at the home were safeguarded and therefore records were not inspected on this occasion. Information relating to individual financial arrangements, advocacy support or reasons and legal basis for residents not able to manage their own financial affairs was not recorded in their care plans. Discussions with management and staff indicated that issues relating to the identification and prevention of abuse were understood and the home had appropriate Protection of Vulnerable Adults protocols in place. Ash Croft DS0000017750.V301969.R01.S.doc Version 5.2 Page 18 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, 22, 23, 24, 25 & 26. Ash Croft offers a comfortable and pleasant living environment. The home is clean and well maintained and residents’ bedrooms are personalised and homely. EVIDENCE: A tour of the premises was taken. The home was well maintained and clean throughout with the exception of the staff toilet and changing room. The facilities were very tired looking, unattractive to use and in need of redecoration particularly to the sink area, which did not comply with health and safety and infection control guidelines. A rolling programme of redecoration was evidenced and the bathrooms were being repainted at the time of inspection. The home is currently awaiting approval of plans submitted to the local planning department for an extension to update and improve the environment to meet the needs of the residents, to include an additional lounge, new sluice facilities and additional bedrooms with en suite facilities. The home currently Ash Croft DS0000017750.V301969.R01.S.doc Version 5.2 Page 19 has three shared rooms, occupied by two people. Screening is provided to promote privacy. Bedrooms were personalised with resident’s own belongings. Appropriate equipment was seen around the home to promote optimal independence and reduce health risks such as pressure relieving equipment. The home caters for very frail residents and specialist mobile reclining chairs are provided for those residents who would otherwise be unable to sit in the lounge. The chairs provide more support and comfort than a conventional armchair and can be easily moved around the home. The use of these chairs provide residents more choice about where to spend the day and without them those residents would experience difficulty in spending time out of bed. In some rooms it was noted that bed rails were being used. Risk assessments did not fully address the need for bed rails or whether other methods had been tried. It was indicated in one case that they were in place at a relatives’ request. The manager was advised to seek an assessment and advice from an appropriate health professional. In other instances mattresses were placed on the floor beside the bed to soften the fall in potential cases. There were no grab rails and protective coverings to radiators in the corridors and this is an issue the home is addressing. The home is managing high continence needs successfully and no unpleasant odours were evident. Robust infection control policies and procedures were in place. Ash Croft DS0000017750.V301969.R01.S.doc Version 5.2 Page 20 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 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The numbers and skill mix of staff was adequate to meet the assessed needs of the service users. The service had not achieved an adequate proportion of carers having attained a National Vocational Qualification. Induction and foundation training for new staff did not fully meet Skills for Care requirements. Records relating to staff recruitment were satisfactory. EVIDENCE: Examination of duty rotas and discussions with staff gave evidence that staffing numbers provided adequate support to meet the assessed needs of the residents. At the time of inspection, the service had not yet achieved an adequate proportion of carers having attained a National Vocational Qualification (NVQ) in care at level 2, or a date by which this will be achieved. The inspector was informed that out of a total of 21 care staff only 2 had achieved the NVQ level 2. Ash Croft DS0000017750.V301969.R01.S.doc Version 5.2 Page 21 A sample of three staff files was examined. They were disorderly and in need of organisation. Recruitment of overseas staff was handled by an external agency that ensured all references and documentation was validated. References had been received but staff confirmed they had removed them from their files to be used for other purposes. The manager was advised to maintain copies and a pro forma developed by CSCI was provided to check and record evidence of receipt of all required documentation. All files contained a satisfactory Criminal Record Bureau and POVA First check. The homes induction arrangements is mainly service focused and although it provided the support new staff required and informed them of the culture of the home, it was not in line with National Training Organisation specification. One new member of staff spoken with had commenced employment the week of the inspection. She indicated that staff and management were helpful and informative. From observation it was not evident that she was being supervised, monitored or following a comprehensive induction process. Discussion with the manager advised that all new staff must be registered on a Skills for Care programme, the newly formed occupational training council for the social care sector, as from September 2006. It was also recommended that existing staff not yet commenced NVQ level 2 in care should be considered for the induction and foundation programme. Mrs Crowley, the registered manager is a Registered Nurse and an NVQ assessor, reviewed regularly by the Suffolk College Consortium. She undertakes training needs assessment of the staff individually and the group as a whole to inform a training and development plan. The majority of staff mandatory and specialist training is provided in house and assessment of staff competence was evident including multiple choice tests and essays. This level of training is adequate as an induction level of training to support staff in provision of a care service. Staff spoken with demonstrated a good understanding and a basic level of knowledge about the people living in the home. However further development is required in the programme to ensure the basic level of training is complemented by further initiatives and structured training. Elements of specialised practice such as validation and reminiscence therapy, communication, ‘life histories’, activities and person centred planning need to be developed to enhance their level of understanding of dementia care. Ash Croft DS0000017750.V301969.R01.S.doc Version 5.2 Page 22 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, 32, 33, 35, 36, 37 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The Registered Manager is a person of good character and is fit to be in charge of the home. Ash Croft is well managed and staff receive leadership, guidance and direction to ensure the residents receive consistently good care. The Registered Manager has a clear vision for improving the service users quality of life but needs to develop a system to monitor and review quality outcomes. Planned formal supervision for staff is not consistent. Robust policies and procedures were in place to guide staff. Ash Croft DS0000017750.V301969.R01.S.doc Version 5.2 Page 23 Some issues need to be addressed within the home to promote the health, safety and welfare of residents. EVIDENCE: The Registered Manager, Mrs Crowley, has operated Ash Croft for many years. Mrs Crowley is a qualified Registered Nurse and has successfully completed NVQ level 4 in care and management. The Registered Manager is dedicated to the care of the residents in her home. She operates an open door policy to residents, their representatives and staff. The staff felt well supported in their roles and confirmed any issues identified were dealt with as they arose. Mrs Crowley, the Proprietor and Registered manager resides in close proximity to the home. Staff confirmed that there was good contact during the day and night between the manager and the staff and the residents. Visitors to the home spoken with expressed satisfaction with the home and felt welcomed and included in their relatives care. Quality monitoring and assessment specific to dementia care outcomes was not yet developed. It is important that a method to measure the way in which quality care is provided and outcomes for residents at the home is extended. Ways of obtaining the views of people with dementia needs to be explored to ensure the home is run in the best interests of the residents and the quality of life for people with dementia is promoted. From the sample of staff files examined, records of formal one to one meetings indicated a need for discussions to have a stronger link to care practice issues and the integration of knowledge with practice to meet the needs and objectives of the individual residents. Supervision meetings need to be more regular. Robust and comprehensive policies and procedures were in place to guide and support staff in health and safety issues and good care practice guidance. Records relating to the promotion of the health, safety and welfare of residents and staff were maintained. Sluicing facilities and the installation of grab rails in corridors and radiator guards must be addressed to free the home from hazards to resident’s safety. Ash Croft DS0000017750.V301969.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 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 3 17 3 18 3 3 X 3 2 3 3 2 2 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 2 3 3 2 3 2 Ash Croft DS0000017750.V301969.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 OP2 Regulation 17(2) Sch 4 Requirement The Registered Person must provide each service user with an individually costed contract/statement of terms and conditions of residence. This is a repeat requirement. Timescale for action 30/08/06 2. OP3 14 2. OP26 OP38 13(3) 3. OP22 OP25 OP38 13(4)(a) 30/08/06 The Registered Person shall not provide accommodation to a service user at the care home unless a copy of a needs assessment has been obtained and the registered person has confirmed in writing to the service user that having regard to the assessment the care home is suitable for the purpose of meeting the individuals needs in respect of health and welfare. The Registered Person shall 30/10/06 make suitable arrangements to prevent infection and the spread of infection in the care home. The Registered Person shall 01/10/06 ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety. DS0000017750.V301969.R01.S.doc Version 5.2 Page 26 Ash Croft 4. OP28 18(1) (a)(c) 5. OP30 18(1) ( c) (ii) 6. OP33 24(1)(a) (b) 7. OP36 18 (2) The Registered Person shall ensure that at all times suitably qualified, competent and experienced persons are working at the care home for the health and welfare of service users and ensure that persons employed at the care home receive training appropriate to the work they are to perform. The Registered Person shall ensure that persons employed at the care home receive suitable assistance, including time off, for the purpose of obtaining further qualifications appropriate to such work. The Registered Person shall establish and maintain a system for reviewing at appropriate intervals and improving the quality of care provided at the home. The Registered person shall ensure that persons working at the home are appropriately supervised. 01/10/06 01/01/07 01/10/06 01/08/06 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. 3. Refer to Standard OP7 Good Practice Recommendations The Registered Person should ensure the care planning process is service user focused reflecting strengths and all assessed needs, support required and expected outcomes. The Registered Person should ensure regular activities are provided and suited to individual needs and people with dementia to promote well-being. The Registered Person should ensure staff facilities are up kept. DS0000017750.V301969.R01.S.doc Version 5.2 Page 27 OP12 OP19 Ash Croft Ash Croft DS0000017750.V301969.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ash Croft DS0000017750.V301969.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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