Inspection on 25/10/07 for Ashbourne

This inspection was carried out on 25th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Ashbourne 05/11/08

Ashbourne 06/05/08

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 Ashbourne 12 Neale Avenue Kettering Northamptonshire NN1 4BS Lead Inspector Rob Cooper Unannounced Inspection 09:40 25 October 2007 th 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 Ashbourne DS0000070317.V351348.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. Ashbourne DS0000070317.V351348.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashbourne Address 12 Neale Avenue Kettering Northamptonshire NN1 4BS 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) 01604 475333 Msaada Care Limited Mrs Gail Sharman Care Home 18 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (17) of places Ashbourne DS0000070317.V351348.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered persons may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission are within the following categories: Old Age - Code OP. 2. Dementia - Code DE(E) (maximum 1). The maximum number of service users who can be accommodated is 18. New owners – so this is considered a first inspection Date of last inspection Brief Description of the Service: Ashbourne is situated on a residential street close to the edge of town with street parking to the front. The building is a large detached care home covering two floors, with an office and storage space in the cellar. There is a passenger lift to take residents who might not be able to manage the stairs to the upper floor. To the rear of the property is a pleasant enclosed garden with a patio area. A company called Msaada bought Ashbourne in June 2007, however a full change over to Msaada’s documentation and procedures has not yet been completed. Fees: Information relating to the fees was not available at this key inspection visit. Ashbourne DS0000070317.V351348.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 visit as part of the key inspection process – so that no one at Ashbourne knew that the inspection visit was going to take place. The visit took approximately five hours through the middle of the day with one inspector present. The method used to carry out this key inspection visit was to send out an Annual Quality Assurance Assessment (known as an AQAA) for Ashbourne to self assess their service. This had not been returned by the date of the inspection visit, and therefore did not provide any information, which informed this inspection process. This was followed with a visit to Ashbourne, where a method called case tracking was used; this involved identifying four residents and looking at their individual files and making a judgement about the quality of care they are receiving, and if their needs are being met. This was done by a partial tour of Ashbourne, looking at the activities on offer, and talking to one resident, and two members of staff about the quality of the service, and their experiences of living and working at Ashbourne. The deputy manager provided the information, as the registered manager was not available during this inspection visit. There were twelve residents in residence. Prospective residents can obtain information about Ashbourne direct from the care home, and this would include seeing previous inspection reports prepared by the Commission for Social Care Inspection. Information can also be found about Msaada who operate Ashbourne at their web site at: www.msaada.co.uk What the service does well: Ashbourne has a pleasant, private garden, and there are a number of small sitting areas so that residents can spend time apart if they so wish. Bedrooms are of a reasonable size and are comfortable and homely. Ashbourne DS0000070317.V351348.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: As a result of this inspection visit sixteen requirements and twelve good practice recommendations have been made: Requirements relate to: * The Statement of Purpose and service user guide must be available and copies given to every resident. * Every resident must have a copy of their contract and/or terms and conditions of residence. * Resident’s care needs must be based on a formal assessment. * Care plans need to be more detailed, so they are able to instruct staff in how to meet resident’s needs. * Care plans must be reviewed regularly to ensure that resident’s changing needs are still being met. * Care plans must be in place to meet resident’s specific healthcare needs. * Residents must be consulted with about a programme of social and leisure activities. * There must be a complaints procedure in place, which will guide individuals in how to make a complaint, and to whom they should complain. * A record of all complaints received must be kept, together with the outcome of any investigation into those complaints. * Every member of staff must receive training in safeguarding adults procedures. * Every member of staff must have a Criminal Records Bureau check. * Every member of staff must have two written references. * A Quality Assurance system to review the quality and improvement of Ashbourne must be put in place. * The provider (Msaada) must carry out monthly monitoring visits to Ashbourne in line with Regulation 26 of the Care Standards Act 2000. * All members of staff working at Ashbourne must be properly supervised. * Regular testing of the health & safety systems at Ashbourne must be carried out to ensure residents and staff are safe. Good practice recommendations: Ashbourne DS0000070317.V351348.R01.S.doc Version 5.2 Page 7 * Care plans should be reviewed monthly * Photographs should be used in the medicine file to aid staff recognising individual residents. * Any resident who is taking their own medicines should have a care plan and risk assessment in place. * Staff should do more to meet resident’s social needs through talking and structured activity. * Resident’s care files should record more detail relating to resident’s wishes at the time of their death. * There should be more choice. * There should be at least two choices at meal times. * Staffing levels should be reviewed to meet all of the resident’s needs. * Staff training records should be improved * Resident’s meetings should be introduced. * Record keeping for resident’s finances should be improved. * Every member of staff should have formal supervision at least six times a year. 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. Ashbourne DS0000070317.V351348.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 Ashbourne DS0000070317.V351348.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): 12&3 Quality in this outcome area is poor; this judgement has been made using available evidence including a visit to this service. Prospective residents at Ashbourne did not have sufficient information before they moved in to make an informed choice about where to live. Currently residents are not well informed about the services Ashbourne offers. Ashbourne does not offer intermediate care. EVIDENCE: Ashbourne have a brochure/ prospectus but copies of this were not seen during the inspection visit, and the staff members on duty were not aware where copies were kept. These documents are also known as the Statement of purpose and the service user guide, Care Homes Regulations say that copies of both must be in place and must be made available to residents, one resident who was asked said she had not seen a copy. Ashbourne DS0000070317.V351348.R01.S.doc Version 5.2 Page 10 A blank copy of the contract was seen in the policy file, however no contracts or terms and conditions of residence documents were seen in any of the resident’s files, and staff were not able to produce copies when asked. Four resident’s files were seen as part of the case tracking process, however none contained a formal assessment of needs, and there was no indication where if at all, the assessments were stored. Ashbourne DS0000070317.V351348.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 poor; this judgement has been made using available evidence including a visit to this service. The residents do not currently have their health and personal care well managed, supported and recorded by the staff at Ashbourne. EVIDENCE: The four resident’s files that were seen showed that each person had a plan of care in place, although as already stated, it was not possible to see the assessments on which this plan of care was based. The daily notes section of the files had been completed regularly, however care plan reviews had not taken place since March 2007, and many of the care plans were also very out of date, with no recorded entries since early 2007. One particular care plan clearly stated that it should be ‘reviewed monthly’ but had not been reviewed since December 2005. In general the care plans were very superficial and did not direct staff in how to meet resident’s needs, or record information in any structured method on which to base a review, or to monitor progress. Ashbourne DS0000070317.V351348.R01.S.doc Version 5.2 Page 12 The four files again showed poor care plans relating to health, with one resident identified as being diabetic, but all information being recorded in the daily notes. There was no specific care plan for the diabetes, or instructions to staff of what to be aware of, or monitoring of any sort. A regular six weekly chiropodist appointment was also recorded in the daily notes, rather than in a care plan specifically for the purpose. Medication at Ashbourne is provided by the local co-op pharmacy. There is a NOMAD system in place – a pre-packed monitored dosage system, which makes it easier for the staff to administer. The administration records did not have any photographs to aid the identification of residents, there were also some gaps in the administration records, and no signatures to show that medication had been booked in. One of the resident’s files identified that this individual self medicated, however there were no risk assessments or care plans relating to medication in this person’s file. Staff when asked, said that the manager had showed them how to administer medication, with information and training being handed down internally. There were no training records in place to show that staff had been properly and safely trained to administer medication. Observations of the staff interactions with residents were generally positive, with staff speaking to residents in a polite and friendly manner. Staff were also seen knocking on resident’s doors before entering their bedrooms. However the residents were left for long periods with no staff interaction, in particular several residents were sitting in the lounge with the television on, and the sound turned low, no residents appeared to be watching the television, and one resident said: “We are waiting, I don’t know what for” I asked if the lady had, had her breakfast? To which she replied: “Yes we’ve had that.” Each of the four resident’s files that were seen contained a front sheet which had space to record the resident’s last wishes or funeral arrangements. Two files had this section left blank, and two contained the words: ‘contact son or daughter’. If a resident’s death is to be handled in a caring and dignified manner, it is important to record as much information as possible about the individual and their family’s wishes at the time of death, preferably in a care plan specifically for the purpose. Ashbourne DS0000070317.V351348.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. Residents at Ashbourne do not have a lifestyle that reflects their cultural, social and religious interests, and needs. EVIDENCE: During the five hours of the inspection visit no structured activities for residents were seen to be taking place. Residents were either in their bedrooms occupying themselves or were sat in the lounge in front of the television. Ashbourne was very quiet with little conversation of social interaction between the residents, and very little social interaction between the staff and residents. Documentary evidence was seen that a lady comes in to do ‘exercises with the residents’ on a Monday, and staff said that sometimes singers come in to entertain the residents, although they could not remember when they last came, and there were no written records to show what activities were taking place, and which residents were attending. Discussions with one resident about family contact, indicated that families were able to visit, and did come regularly, and staff did make visitors welcome. A sign in the foyer asked that visiting was restricted to 10-8 through the day. No Ashbourne DS0000070317.V351348.R01.S.doc Version 5.2 Page 14 relatives were visiting Ashbourne during this inspection visit, so it was not possible to get the views of any relatives to help inform the inspection process. During the entire inspection visit no evidence was seen that would indicate that residents were offered any level of choice within their lives. This is based on observations of the staff going about their duties and inspection of written records. The menu offers only one choice of meal, although staff said that if someone wanted something different they only had to ask, discussions with staff members about this showed that in real terms this would present a very limited choice of alternatives. The main meal was being prepared during the morning ready for lunch, and looked to be of good quality and in sufficient amounts to meet the needs of the residents, although as already identified choice was very limited, and this limited choice was seen to continue through the set weeks menus, with only one option for lunch identified on any given day. Ashbourne DS0000070317.V351348.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 poor; this judgement has been made using available evidence including a visit to this service. Residents at Ashbourne are potentially unsafe, and their complaints are not taken seriously and dealt with. EVIDENCE: It was not possible to see how man complaints had been received at Ashbourne since the last key inspection in March 2007, as no record of complaints could be found within the home. The complaint’s procedure on display in the foyer is out of date, and needs updating, as it does not contain details of timescales, or direct a complainant to the correct bodies should they be unhappy with the outcome of their complaint. Discussions with staff members indicated that issues relating to safeguarding adults were covered in National Vocational Qualification (NVQ) training, but staff had not received any specific training in this area. This training is aimed at raising staff awareness of abuse, and through raising the issues, offering residents greater protection against abusive practice, while also showing the staff the correct procedures to follow should they encounter abusive behaviour. A review of staff training records also showed that training in safeguarding adults was not adequate. Ashbourne DS0000070317.V351348.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 & 29 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to this service. Residents at Ashbourne live in a safe, clean and comfortable home, with their personal possessions around them. EVIDENCE: A partial tour of Ashbourne showed it to be comfortable and reasonably homely, with a number of different sitting areas for residents. Resident’s bedrooms were comfortable and one resident said: “It’s very nice” when asked about their bedroom. To the rear of the property is a private garden with different sitting areas and small lawns and flowerbeds. The home is well equipped with aids to assist those residents with restricted mobility in the bathroom and toilet. Ashbourne DS0000070317.V351348.R01.S.doc Version 5.2 Page 17 Discussions with the staff indicated that Ashbourne employ a cleaner, although as the cleaner was on holiday, the care staff were covering the cleaning duties. The building was clean, and tidy and one resident who was spoken with said: “They work hard to keep it clean, it’s always very nice.” Ashbourne DS0000070317.V351348.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. Staff at Ashbourne have not been recruited professionally, and it is unclear if they are competent and properly trained to do their jobs. EVIDENCE: A review of the staffing rota showed that usually there are two members of staff on duty for each shift during the day, with a waking night staff together with a ‘sleeping in’ member of staff who is available in emergencies. The rota identified nine staff members on the Ashbourne team, with additional staffing being brought in when needed from other care homes within the group. Both members of staff when asked thought there were enough staff to meet the resident’s needs, although as already identified, observations suggested that the staff were only meeting resident’s physical needs, not their social, cultural or recreational needs, and for this there will need to be a review of staffing levels. The care industry considers National Vocational Qualifications (NVQ) to level II in care to be the basic qualification for staff working in residential care. A review of the training records showed that there are four staff members with NVQ qualifications, a further six are studying for their NVQ level II. It is recommended that a minimum of 50 of the care team are NVQ qualified, and the staff team at Ashbourne are currently working towards this figure. Ashbourne DS0000070317.V351348.R01.S.doc Version 5.2 Page 19 Initially four staff files were seen, however as a problem with Criminal Records Bureau checks was identified, every member of staff at Ashbourne had their file checked. The object of checking the staff files was to see if they contained all of the information that would show that staff had been recruited in a safe manner – in that applicants had filled out an application form, provide two written references and undergone a Criminal Records Bureau check. A review of the documentation showed that there were two members of staff without Criminal Records Bureau checks, and three members of staff with only one written reference, rather than the two required. This evidenced that the current recruitment process had not worked to protect residents. A review of the staff training records showed them to be unclear. There is undoubtedly some staff training taking place at Ashbourne, but the records did not identify what training individuals had done, what they needed to do, or if and when any update training was due. Ashbourne DS0000070317.V351348.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 36 & 38 Quality in this outcome area is poor; this judgement has been made using available evidence including a visit to this service. Ashbourne is not currently a safe, well-managed care home with good systems for ensuring it’s quality or health & safety in place. EVIDENCE: On the day of the inspection visit the registered manager was not on duty and was therefore not seen by the inspector. She has been through the Commission for Social Care Inspection’s registration process in the past, and been deemed suitably qualified and experienced to fill the post of registered manager. During the inspection visit a copy of resident’s survey (in the form of a questionnaire) was seen, however there was no evidence that the surveys had Ashbourne DS0000070317.V351348.R01.S.doc Version 5.2 Page 21 been distributed in a formal manner, or that the results of the survey had been evaluated. A member of staff said that resident’s meetings were not taking place, and the resident who was spoken with also said there were no meetings. Copies of Regulation 26 visits – formal monitoring visits by the provider or their representative were not available for inspection, and there did not appear to be a working quality assurance system in place. Ashbourne have a ‘small cash needs’ system for resident’s personal finances. The records for four residents were checked, and no errors were found. Receipts were in place to evidence expenditure and all cash totals tallied. However the records of cash transactions are recorded on pages torn from a notebook, and it is recommended that the record keeping of resident’s finances is put on a more formal and professional footing. Discussions with two members of staff evidenced that they are not receiving formal supervision, and had not received any for several months. No supervision records could be located, and therefore none were seen. A number of health & safety records were seen, including the fire safety records, these indicated that regular health & safety testing, and monitoring is not happening at Ashbourne, which potentially leaves residents and staff at risk. Ashbourne DS0000070317.V351348.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 1 1 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 3 X X X X X X 3 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 3 X 2 X 2 2 X 2 Ashbourne DS0000070317.V351348.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? N/A 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 OP1 Regulation Requirement Timescale for action 15/12/07 2. OP2 3. OP3 4. OP7 5. OP7 Regulation A copy of the service user guide 4 and the statement of purpose setting out Ashbourne’s aims and objectives and the services and facilities on offer, must be available in the home for inspection, and a copy must be given to each individual resident. Regulation Every resident must have a copy 5 of their contract with Ashbourne or a copy of the terms and conditions of residence as appropriate. Regulation The care needs of every resident 14 must be based on a formal assessment either carried out by a health or social care worker before the resident is admitted, or carried out by suitably qualified or experienced staff from Ashbourne, which ever is the most appropriate. Regulation Care plans must contain more 15 (1) detail so as to instruct staff in how resident’s specific needs are to be met Regulation Care plans must be reviewed 15 (2) b regularly to ensure that they are still able to meet resident’s DS0000070317.V351348.R01.S.doc 15/12/07 31/12/07 31/12/07 31/12/07 Ashbourne Version 5.2 Page 24 6. OP8 7. OP12 8. OP16 9. OP16 10. OP18 11. OP29 changing needs. Regulation Care plans must be in place to 12 (1) promote resident’s health and welfare, and in particular residents who have specific health care needs must have care plans in place for the monitoring and recording of information related to that health care need. Regulation Residents must be consulted 16 (2) n with about a programme of activities that will meet their social needs and interests. Regulation There must be a complaints 22 procedure in place, which will inform people how to complain, whom to direct their complaints to, and the timescale for a response, together with what action to take should the complainant not be satisfied. Regulation A record of all complaints 22 received, together with details of any investigation into the complaint, and the outcome, including the timescale must be kept, and made available for inspection at Ashbourne. Regulation All staff must receive formal 18 (1) c training in safeguarding adults procedures, so that residents are protected from abusive practice, and staff are aware of the correct procedure to follow should they encounter an abusive situation. Regulation Every member of staff must 19 have a Criminal Records Bureau check carried out, and staff must not work at Ashbourne unsupervised unless they have had a satisfactory Criminal Records Bureau check returned. In the short term staff members can work in a supervised capacity if they have a POVA first check in place. However the DS0000070317.V351348.R01.S.doc 31/01/08 31/01/08 15/12/07 15/12/08 30/04/08 15/12/07 Ashbourne Version 5.2 Page 25 12. OP29 Regulation 19 13. OP33 Regulation 24 14. OP33 Regulation 26 15. OP36 Regulation 18 (2) 16. OP38 Regulation 23 POVA first check is a short-term measure until the Criminal Records Bureau check has been completed. Every member of staff must have two written references provided, and available for inspection. This is a requirement for every member of staff irrespective of how long they have been employed. A system for reviewing the quality of Ashbourne and improving (A Quality Assurance system) must be developed and put in place, and be available for inspection. The provider or their representative must visit Ashbourne on a monthly basis to carry out a formal Regulation 26 visit. Copies of the report of that visit must be held at Ashbourne and be available for inspection. All members of staff working at Ashbourne should receive regular formal supervision, with records kept and available for inspection. Regular testing and monitoring of the health & safety systems at Ashbourne must be carried out, and records kept, and available for inspection, to ensure the health & safety of the residents and staff. 15/12/07 31/01/08 30/11/07 31/01/08 30/11/07 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 Ashbourne DS0000070317.V351348.R01.S.doc Version 5.2 Page 26 1. 2. 3. OP7 OP9 OP9 4. 5. 6. OP10 OP11 OP14 7. 8. 9. 10. OP15 OP27 OP30 OP33 11. 12. OP35 OP36 Resident’s care plans should be reviewed monthly as recommended by the National Minimum Standards. Photographs of residents should be used within the medicine file to aid recognition, particularly for staff who are not familiar with Ashbourne or it’s residents. Any resident who is identified as self-medicating should have a care plan and risk assessment in place to ensure that staff are aware of all of the issues and risks involved, and know how best to support the resident in their selfmedication. The staff should meet resident’s social needs as well as their health and physical needs. This will entail talking to residents and engaging them in conversation and activity. Resident’s files should include care plans relating to death and dying, which include resident’s and their family’s wishes at the time of death. Residents should be offered the opportunity to exercise choice in all aspects of their lives, and wherever possible this choice should be recorded in resident’s files to evidence that the choice has been offered, and a choice made, which will show that residents have control over their lives. The menu should offer at least two alternatives for the main meal of the day, with a record kept of choices made by individual residents in respect of the food that they eat. Staffing levels should be reviewed to ensure that there are sufficient numbers of staff on duty to meet all of the resident’s needs – health, social, recreational and cultural. Staff training records need to be formalised, so that they are clear, and it possible to identify what training individuals have attended, and what training they require. Formal resident’s meetings should be introduced and held regularly, with minutes kept, to evidence that residents are consulted about life at Ashbourne, and have a formal voice in the running of the home. Record keeping for resident’s finances should be on a more formal and professional basis. Every member of staff should receive formal supervision a minimum of six times a year. Ashbourne DS0000070317.V351348.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. 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