Inspection on 14/05/07 for Ash Villa Care Home

This inspection was carried out on 14th May 2007.

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 no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Ash Villa Care Home 159 Musters Road West Bridgford Nottingham NG2 7AF Lead Inspector Michael Williams Unannounced Inspection 14th May 2007 10:00 Ash Villa Care Home DS0000068982.V336697.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ash Villa Care Home DS0000068982.V336697.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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ash Villa Care Home DS0000068982.V336697.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ash Villa Care Home Address 159 Musters Road West Bridgford Nottingham NG2 7AF 0115 982 6644 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) MGB Care Services Limited Mr David Copley Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Ash Villa Care Home DS0000068982.V336697.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. MGB Care Services Limited is registered to provide accommodation and personal care at Ash Villa Care Home, 159 Musters Road, West Bridgford, Nottingham for people whose primary care needs fall within the following categories and numbers: Learning disability (LD) 9 Date of last inspection Brief Description of the Service: Ash Villa is large detached purpose built house owned by MGB Care services Limited. The house is situated in West Bridgford within walking distance of the town centre with good access to a variety of local amenities. The home, which is owned by MGB CARE SERVICES LIMITED, is large and spacious with a walk through dining room and lounge. There is parking space for several cars at the front and there is a private are well maintained garden. The premises has three floors, which are all occupied by residents, access to the ground is by stairs and passenger lift. The home has nine bedrooms which all have en-suite facilities available to residents. The fees are currently from £967.59 to £1833 calculated on the level of dependency. This does not cover items such as holidays, weekend socialising, clothing, or personal equipment. This information is made available to prospective residents upon request. Ash Villa Care Home DS0000068982.V336697.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced undertaken one inspector, the registered manager was available for part of the inspection and provided valuable assistance as did other staff present. The focus of the inspection undertaken by the Commission for Social Care Inspection is upon outcomes for residents, and their views on the service provided. This process considers the providers capacity to meet regulatory requirements, minimum standards of practice, and focuses on aspects of service provision that require further development. The main method of inspection used was called ‘case tracking’ which involved selecting two residents and tracking the care they receive through checking their records and discussion with them, making observations of the care received and asking staff about their needs. We were unable to communicate with some resident who have a limited ability to understand and communicate. Therefore some judgements in this report are from the observations of staff and resident interactions. Two members of staff and one set of relatives were spoken with as part of the inspection other residents who were not part of the case tracking were observed and opinions about the quality of their care sought. Documents and medication policy and practice were examined as part of the inspection to gain evidence and form an opinion about the residents health and safety. A partial tour of the premises was undertaken which included communal areas, and a sample of bedrooms were viewed to ensure that the environment was pleasant, homely and safe. A review of all the information about the home received by the Commission since the last inspection was taken into consideration in planning this inspection and helped in deciding what areas of care were looked at. What the service does well: An assessment is undertaken to identify if the home can meet individual need before residents are offered a place at the home, trial visits are offered to prospective residents. Care plans are developed from pre- admission assessments and provide detailed information about meeting the needs of residents. Residents are treated with respect and dignity; interaction between staff and residents is meaningful. Ash Villa Care Home DS0000068982.V336697.R01.S.doc Version 5.2 Page 6 Residents are offered opportunities and supported in personal development and accessing community activities. The home has a relaxed atmosphere, daily activities in the home are client led, and residents are encouraged and supported to lead the lifestyle that they choose. Relatives and friends are made to feel very welcome when they visit. A varied, healthy and nutritious diet is offered to people living at the home. There is a suitably qualified and experienced manager in place who has an open and relaxed management style, suited the needs of residents and their representatives. What has improved since the last inspection? What they could do better: Assessments should consider holisitic need and include the cultural and diverse needs of residents. Care plans and risk assessments should identify the reason why restrictions on individual rights have been imposed, and should include dates and signatures of when restrictions were introduced and reviewed. Consent to restrictions on rights must be sought from residents or their representatives. Care plans should be kept under regular review, and should evidence that resident or their representatives are involved in the development of care plan. Procedures to assess individuals’ ability to manage and administer their own medication should be considered. Household tasks the service user is responsible for should be identified within the care plans. To ensure that residents are protected a copy of staff training records should be kept in the home to evidence attendance to relevant training. Routine building maintenance should be undertaken to ensure that the residents live in a safe environment. To ensure that residents views about how the home is run are taken into consideration, an effective quality assurance system should be in place. Ash Villa Care Home DS0000068982.V336697.R01.S.doc Version 5.2 Page 7 To maintain confidentiality all records containing personal information should be securely locked away. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ash Villa Care Home DS0000068982.V336697.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ash Villa Care Home DS0000068982.V336697.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5 Quality in this outcome area is good Residents are provided with sufficient information to make an informed choice before moving into the home. Assessment of individual need is undertaken to ensure that the home can meet the needs residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose and the Service User Guide provides sufficient information for prospective residents to make an informed choice about moving into the home. This information is also available to in tape format. Resident relatives confirmed that trial visits are offered to assess available facilities and the suitability of the home, before making a decision to move in. Before residency is offered the manager undertakes an assessment of need using available information from extended Community Care assessments, prospective residents and their representatives, and information from other professionals who are involved in the lives of the resident. Ash Villa Care Home DS0000068982.V336697.R01.S.doc Version 5.2 Page 10 Files examined contained pre admittance assessments, however, there was no evidence or confirmation that the home could meet the assessed needs of residents. The files did not contain a specific contract to indicate the Terms and Conditions of the placement. The manager said that copies of resident contracts were filed at the MGB Care Homes head office. Ash Villa Care Home DS0000068982.V336697.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 and 9 Quality in this outcome area is adequate Individual needs are assessed, residents are provided with opportunities to make decisions about their lives. Residents are not consulted and do not participate in the planning or review of their care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Risk assessments provided good detail about strategies to support and manage residents challenging behaviours, and are used to inform the development of care plans. Care planning documentation is well organised and provide sufficient information about residents history, health, personal and social needs and behaviours. Residents are assessed on their level of understanding and ability, and are encouraged and supported in maintaining their independence. Short and medium personal goals are reflected in care plans. Ash Villa Care Home DS0000068982.V336697.R01.S.doc Version 5.2 Page 12 There was little evidence to indicate that the cultural and ethnic needs of one case tracked resident had been considered in informing the development of their care plan. For example there was little information in the care plan about hair and skin care, and there was no evidence of the resident’s cultural dietry needs or prefences being explored. One care plan identified that a resident’s TV had been removed from their bedroom for the resident’s safety. There was no evidence to indicate that the resident or their representatives had consented to restrictions being imposed on the resident’s rights. The risk assessment for the restriction had not been reviewed within the home’s agreed timescales, which placed the resident at risk of potential abuse. There was no evidence that residents or their representative are consulted or participate in the planning or review of their care. Staff spoken with demonstrated a good level of awareness and understanding of individual resident’s personalities and individual need. Staff also provided good examples of how residents are supported to make decisions about their lives. This included undertaking risk assessments to empower and enable residents to participate in chosen activities such as swimming, trampoline and going out in the community independently. Discussions with residents and staff indicated that residents are encouraged to take part in aspects of life around the home and are responsible for tasks such as putting dirty laundry in the laundry basket and clearing tables after meals; these tasks are not recorded in care plans. Ash Villa Care Home DS0000068982.V336697.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is Good Residents are supported and provided with opportunities for personal development; family and social relationships are encouraged. As part of promoting healthy lifestyles residents are offered a nutritiouis, varied and balanced diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection some residents had gone to college and day centres, those who were at home were observed getting out of bed when they wished and making decisions about what they wanted to do with their day. Interactions between staff and residents were observed to be courteous and respectful, with staff demonstrating their support for the residents through their responses to requests, and undertaking meaningful conversations. Ash Villa Care Home DS0000068982.V336697.R01.S.doc Version 5.2 Page 14 It was evident from observing and speaking with residents and staff that there are regular, and spontaneous, opportunities to go out into the community. Residents said that they go to a weekly disco, play snooker and pool and visit the local shops and pubs. This was confirmed by discussions with the relative of one resident and staff. Residents are encouraged to develop daily living skills and to take some responsibilities around the home for helping with their laundry, preparation of meals; however, this information was not recorded in the care plans. Maintaining family and social relationships are encouraged and supported, there is a pay phone, and residents also have access to the main office phone. The manager and staff said that family contact is encouraged and supported wherever possible; residents and relatives spoken with confirmed this. Menu records indicated healthy, nutritious meals are offered to residents. On the day of the inspection the cook was on sick leave, staff on duty prepared a lunch of pasta bolognaises which was agreed with the residents. Staff were observed eating lunch with the residents in a relaxed and pleasant atmosphere, residents said that they enjoy the food provided by the home. Ash Villa Care Home DS0000068982.V336697.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19, 20 and 21 were inspected on this occasion. Quality in this outcome area is good Health needs are met; residents are treated with respect and dignity. Residents are protected by the homes medication policy and practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans contained detailed information about how staff should support residents with personal care. Files evidenced that the physical care needs of residents are met. The care planning documentation was well organised and included information about interventions and input from consultants, psychiatrists, and district nurse. Residents spoken with said that they were able to see their GP if they felt unwell. Staff said that they found care plans useful and effective for working with the residents. Staff are encouraged to contribute to the care planning process by reporting any concerns to the manager or senior staff so that care plans can be amended if required. The care plans did not evidence regular reviews of care are being undertaken to meet the changing needs of residents. There was no evidence to suggest Ash Villa Care Home DS0000068982.V336697.R01.S.doc Version 5.2 Page 16 that care plans had been developed with input from residents or their representatives The medication policy was examined; appropriate procedures are in place for the ordering, storage and disposal of medication. There were no procedures in place to assess individual resident’s ability to manage their own medication, or consent to their medication being managed by the home. Procedures for medication administration were observed, there were no gaps in Medication Administration Records chart (MAR). Residents are protected by Medication administration policy and procedures. Ash Villa Care Home DS0000068982.V336697.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good Residents are protected from abuse, and are confident that their complaints will be listened to, taken seriously and acted on. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a complaints policy and procedure, which contains information about who to contact to make complaints, and includes timescales for responses to complaints. The last recorded complaint was on 21.04.07, which was satisfactorily dealt with. The Commission for Social Care Inspection (CSCI) has not received any complaints regarding the service provision. Resident s spoken with, said that they would tell the staff if they felt unhappy “I feel safe”. One relative spoken with said that they felt confident in approaching the manager if they had a complaint or concerns, and said “residents are kept safe and are well cared for”. Staff spoken with were aware of their responsibilities regarding safeguarding adults and ‘whistle blowing’ policy. Staff said that they had received safeguarding adults training, although this was not evident in the one staff file examined. The manager said that records of staff training are kept at MBG Care Services Limited head office. Ash Villa Care Home DS0000068982.V336697.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,28 and 30 Quality in this outcome area is adequate Residents live in a pleasant and hygienic environment. Residents health and safety may be placed ask risk by maintenance procedures in the home not being maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is undergoing a redecoration programme and it was evident that redecoration of the lounge and dining area was being undertaken. It was clear that consideration had been given to causing a minimum of disruption to the residents, and low odour paint was being used. Any outstanding maintenance repairs are recorded in a maintenance book by staff, the provider employs a maintenance officer who visits the home regularly and is responsible for undertaking minor repairs. A partial tour of the premises was undertaken the premises appeared clean and hygienic throughout; laundry facilities are sufficient for the needs of Ash Villa Care Home DS0000068982.V336697.R01.S.doc Version 5.2 Page 19 residents and are sited well away from the kitchen area. During the tour of the building a filing cabinet was found on the second floor landing that posed a risk to the health and safety of residents, this was removed during the inspection. The lights on the stairs leading to the first floor did not have any bulbs. This poses a risk to the health and safety of residents. The radiator guard on the first floor landing is damaged; this was not recorded in the maintenance book and posed a potential risk to the safety of residents. There have been recent repairs in communal toilets and bathrooms; these areas are now in need of redecoration to make the environment more homely for residents. Resident’s rooms that were viewed were personalised with posters and pictures and portable electrical appliances, although some rooms and areas of the home are ready for redecoration. The garden area was spacious, pleasant and well maintained. Ash Villa Care Home DS0000068982.V336697.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 and 36 Quality in this outcome area is good Residents are supported by competent staff and are in safe hands at all times. Recruitment policy and practices protect residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs both male and female staff of varying ages and differing ethnic backgrounds, and here are sufficient numbers of staff on duty to meet the needs of residents and completed allocated tasks. Staff spoken with had a good understanding of their role and responsibilities for supporting residents, residents and relatives said that they were happy with the support provided by staff, and said “staff are lovely” and are always available. Staff files seen evidenced that appropriate recruitment policy and procedures are being followed, Criminal Records Bureau checks and references are in place. Ash Villa Care Home DS0000068982.V336697.R01.S.doc Version 5.2 Page 21 Staff said that they received regular training and supervision, there was evidence that some staff had completed or are currently working towards National Vocational Qualification in Social Care (NVQ2), and that staff received regular supervision. Some files examined did not evidence that al staff had received an induction; the manager said that a new staff induction has now been implemented in line with ‘Skills for Care’ guidance. Staff administering medication said that they had received training in medication management, staff records examined did not evidence that staff had received medication administration training. The manager said that records of staff training are kept at MBG Care Services Limited head office. Ash Villa Care Home DS0000068982.V336697.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42 and 43 Quality in this outcome area is good The manager is suitably experienced and qualified to manage the home. Residents interests are safeguarded by the policies and procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has over twenty years experience of working in the care sector, he has managed care homes in the public and the private sector. The manager has attained the NVQ 4 Management qualification. There was evidence that the Responsible Individual makes regular visits to the home and produces reports on the findings of the visit as required by Regulation 26. Quality Assurance and Annual Review Systems are in place Ash Villa Care Home DS0000068982.V336697.R01.S.doc Version 5.2 Page 23 There was evidence that resident surveys are carried out; the system operates by residents being asked to completed questionnaires about their views of the service. The Quality Assurance Manager collates these, but there was no evidence of how the outcomes are reported back to residents and their representatives. The manager said that residents are encouraged to express their views in residents meetings. Staff said that that positive and open relationships are maintained with residents, any suggestions from residents are brought to the manager. The home will hold money for residents to pay for personal purchases such as magazines, outings, and visits to the local shops. Examination of financial records evidenced that financial procedures protect residents from abuse. Accident records were viewed and well documented, however there were entries in the book which should have been removed under Data Protection Act 1998. Examination of health and safety documentation evidenced that residents safety and welfare is protected. The manager said that all the required health and safety checks are carried out at the required frequency and there are service contracts in place for servicing all the equipment in the home. Ash Villa Care Home DS0000068982.V336697.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 Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 2 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X 3 3 3 Ash Villa Care Home DS0000068982.V336697.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA2 Regulation 14.1(d) Requirement A copy of of written confirmation that the home can meet the needs of service users must be maintained on service users files in the home. A copy of contract including terms and conditions of placement should be maintained on residents files in the home. Care plans must identify when restrictions on liberty and rights have been imposed for safety, or any other reasons. Service user or their representatives must sign in consent to any restrictions on rights. Care plans must be kept under regular review to ensure the service user’s needs are being met. Residents must be supported to manage their own medication within a risk assessment framework The bulbs to the lights on the stairs leading to the first floor must be replaced. The results of service user surveys must be made available to service users, their DS0000068982.V336697.R01.S.doc Timescale for action 14/07/07 2 YA5 5.1(c) 14/07/07 3 YA6 15(1) 14/07/07 4 YA6 15(2) c, d 14/07/07 5 YA20 12.3 14/07/07 6 7 YA24 YA39 23.2(p) 24.2 14/07/07 14/07/07 Ash Villa Care Home Version 5.2 Page 26 representatives and other interested parties including CSCI. 8 YA41 17(2) Sch4 Completed accident records must 14/07/07 be securely locked away to maintain confidentially in accordance with the Data Protection Act 1998 A that a copy of staff training 14/07/07 record must be made available for inspection. 9 YA39 17(2) Sch4 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. 4. Refer to Standard YA8 YA6 YA24 YA26 Good Practice Recommendations Household task which the service user is responsible for should be identified within the care plan Assessment and Person Centred care plans should identify the ethnic and cultural needs of service users, and how this is considered. The damaged radiator guard on the first floor landing is damaged and must be replaced. A system should be put in place to evidence how outcomes from information collated by The Quality Assurance Manager is reported back to residents and their representatives. Ash Villa Care Home DS0000068982.V336697.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ash Villa Care Home DS0000068982.V336697.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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