Inspection on 06/05/08 for Ashbourne

This inspection was carried out on 6th May 2008.

CSCI found this care home to be providing an Poor service.

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

Ashbourne 05/11/08

Ashbourne 25/10/07

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 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Ashbourne 12 Neale Avenue Kettering Northamptonshire NN16 9HE Lead Inspector Judith Roan Unannounced Inspection 6th May 2008 10:30 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.V364063.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.V364063.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashbourne Address 12 Neale Avenue Kettering Northamptonshire NN16 9HE 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) 01536 513363 Msaada Care Limited Vacant 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.V364063.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. 13th December 2007 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 on the first floor and storage space in the cellar. There is a passenger lift to take people who use the service 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. Ashbourne is owned by Msaada a company who have several other services in the area. Fees: Information relating to the fees is available on application to the homes manager. Ashbourne DS0000070317.V364063.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people who use the service and their views of the service provided. This process considers the services capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. The primary method of inspection used was ‘case tracking’ which involved selecting 3 people who use the service and tracking the care they receive through review of their records, discussion with them, the care staff and observation of care practices. The homes acting manager has completed an Annual Quality Assurance Assessment (AQAA) a questionnaire required to be completed by CSCI. The inspection was unannounced and was undertaken during the morning and afternoon and lasted 6.30 Hours. This inspection included a thematic probe on safeguarding. A thematic probe is how we gather additional information on a particular theme from a key inspection. All key inspections completed 5-16 May 2008 had a thematic probe. What the service does well: What has improved since the last inspection? A copy of the service user guide and the statement of purpose are available in the home. The care needs of every resident are now being assessed. Care plans are now being reviewed regularly to ensure that they are still able to meet resident’s changing needs. Ashbourne DS0000070317.V364063.R01.S.doc Version 5.2 Page 6 A complaints procedure is in place. A record of all complaints received is now available. All staff have received training in safeguarding adults procedures. All staff have a Criminal Records Bureau check carried out prior to commencement of work. Every member of staff has two written references provided. Regular testing and monitoring of the health & safety systems now take place and records maintained. Photographs of residents are used within the medicine file to aid recognition. The menu offers two alternatives for the main meal of the day. Staffing levels have been 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. Formal resident’s meetings have been 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 have been formalised and seen to be kept on a professional basis. What they could do better: Some of the requirements made at this inspection have been repeated from the previous inspection. We consider that, as the provider is now taking positive action to comply enforcement action will not be taken at this time. However we will be monitoring compliance closely. People being assessed for admission must be within the present registration categories. A copy of the service user guide and the statement of purpose setting out Ashbourne’s aims and objectives and the services and facilities on offer, must be given to each individual resident. Every resident must have a copy of their contract with Ashbourne or a copy of the terms and conditions of residence as appropriate. Ashbourne DS0000070317.V364063.R01.S.doc Version 5.2 Page 7 Care plans must contain more detail so as to instruct staff in how resident’s specific needs are to be met. Care plans must be in place to 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. The provider must review their storage of controlled drugs to ensure that they meet the new regulations that came into force in 2007. A system for reviewing the quality of service at Ashbourne and improving it (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. The complaints procedure needs to be displayed so that it is easily accessible. Resident’s care plans should be reviewed monthly as recommended by the National Minimum Standards. It is strongly recommended that a privacy lock be fitted to the ground floor toilet to ensure privacy. 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. 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. Every member of staff should receive formal supervision a minimum of six times a year. Ashbourne DS0000070317.V364063.R01.S.doc Version 5.2 Page 8 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.V364063.R01.S.doc Version 5.2 Page 9 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.V364063.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People using the service have their needs assessed but there is inadequate information available at the initial point of contact. Ashbourne does not offer intermediate care. EVIDENCE: A copy of the statement of purpose and service users guide was available within the home. People who use the service or their family/advocates do not routinely have their own copy. The files contained no evidence that information had been issued and that a contract between the service provider and people using the service had been agreed. The assessed needs of a new resident admitted into the home were available and identified their needs. The information needs to include a detailed social history that would be beneficial to the long term care of their needs. Ashbourne DS0000070317.V364063.R01.S.doc Version 5.2 Page 11 Two other files were case tracked but these did not contain assessments and the provider has not met the requirement made at the last key inspection. New documentation is being implemented and the new manager and their deputy have drawn up a list of priorities to meet this requirement. Ashbourne DS0000070317.V364063.R01.S.doc Version 5.2 Page 12 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 needs of people using the service cannot be fully met, as there is a lack of detailed care plans. EVIDENCE: The care files of three people using the service were seen and two of these had not been updated since the last inspection. Some care plan reviews have taken place and others are planned. The provider has been slow to take action to meet the requirement made at the last inspection in relation to care plans. They remain poor and fail to direct staff on how to meet needs. The new acting manager is working with new care plan documentation and has set out a plan to review all of the needs of people using the service. This documentation will provide detailed information from the assessments to ensure that carers are advised of action to take to meet identified needs. The health needs of people using the service are only met in part. In discussion with one persons relative they were concerned that chiropody treatment that had been available from the NHS due to a diagnosis of diabetes had not been transferred when they had moved into the home. The lack of Ashbourne DS0000070317.V364063.R01.S.doc Version 5.2 Page 13 information on admission gained by the home failed to identify this need. The relative was also unhappy with their family members care and had no trust in the staff to meet their needs. On the day of the inspection it was noted that the person had not had their hair brushed. The relative was aware of the complaint’s procedure but felt that they had not been listened to in the past so was preparing to move their family member to another home. In discussion with the acting manager they were concerned that the relative had not voiced their concerns, as they would be happy to investigate the situation. The needs of another resident were only now being reviewed as a result of the proactive action taken by the acting manager. Their needs could not be fully met by the staff skills at the home. The person had been admitted out of category and required the support of a home providing for people with mental health needs. Daily notes are kept and staff were aware of their responsibilities in recording key information. However without detailed care plans the daily notes only referred to needs met in relation to the existing care plans. Staff were seen to be positive in their approach to people using the service. They were polite and enabled people to choose. Locks have been fitted to all bedrooms to ensure privacy and safety. The locks can be overridden by the master keys in an emergency. The ground floor toilet needs to be fitted with a privacy lock. A pre-packed monitored dosage system, that aids carers to administer, is in place at the home. The acting manager has established a system where there is an identified member of the staff team to be responsible for the administration on each shift. Staff training has been undertaken, however on review of the records errors are reoccurring. The staff member did not convey that they understood the importance that records are correct. In discussion with the manager it was agreed that the staff member would be supervised and monitored to ensure the safety of people using the service. The medication administration records now have photographs to aid the identification of residents. No one at the home self medicates. The medication cabinet is now secured in a ground floor room. Controlled drugs are stored in a cabinet that does not fully meet the regulations. The site of this cabinet also requires two members of staff to leave the floor at times when they need to administer medication. This effectively leaves no support for people who use the service at times throughout the day. The provider is therefore required to review their storage of controlled medication. The recommendation that an individual’s final wishes be recorded has not been undertaken. The new documentation however should address this. Ashbourne DS0000070317.V364063.R01.S.doc Version 5.2 Page 14 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. The social needs are not individually identified which limits choice of activity. Meals are freshly prepared, healthy and there is a choice available. EVIDENCE: On the day of the inspection a volunteer was available to assist with social activities and was observed to have a good rapport with people who use the service. The option available on the day was bingo during the morning. After lunch people watched TV or spent time in their rooms. The lack of social profiles limits the development of person centred activities. Staff training in dementia care has been limited and with the minimum detail available on care files activities are not person centred. Activities are however age related. Families are welcome at the home and can visit as required throughout the day and evening. There is a friendly welcome from staff and privacy is respected. The acting manager has written to all families encouraging them to give feedback about the service. Regular meetings with people who use the service have started and families are welcome to contribute. Meals have changed at the home. There is now a choice of two main meals at lunchtime. Staff ask individuals each morning what they would like to choose from the lunchtime menu. The food is cooked to a high standard with fresh Ashbourne DS0000070317.V364063.R01.S.doc Version 5.2 Page 15 vegetables. A record of the menus is kept on a central file with daily notes recording as necessary for people with nutritional assessment needs. One person who was case tracked had individual support with their meals. Staff were seen to be attentive throughout the mealtime. The acting manager has reviewed access to meals throughout the day and instructed staff to ensure that individual’s have snacks available in the evening especially for those that retire early so that the time between meals is minimised. Ashbourne DS0000070317.V364063.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service can be assured that their concerns and complaints will be listened and appropriate action taken. EVIDENCE: The complaints procedure is available within the information available to people using the service and their relatives. This is situated within the hallway of the home. Relatives have also had letters to inform them that the new manager is available for them to contact if they have any concerns. It is recommended that a summary of the complaints procedure is displayed and accessible to all. The complaints procedure needs to updated to reflect that Social Services is the main point of contact is a complaint has not been resolved. The procedures also needs to updated to give CSCI’s new contact details for the Eastern region. Since the last key inspection there has been one safeguarding referral. A full investigation has taken place that has led to the needs of one person using the service having their needs appropriately met. The acting manager demonstrated that they are fully aware of the local protocols and took steps to protect the people using the service. During the inspection people were asked whether they felt safe at the home all but one confirmed they did. One relative was concerned about the safety of their family member, but was unaware that the safeguarding investigation had made all people using the service safe. Ashbourne DS0000070317.V364063.R01.S.doc Version 5.2 Page 17 All staff spoken with were able to tell the inspector about the types of abuse and what action they would take to protect the people who use the service. The provider has clear whistle blowing procedures and training is available to all staff with regular updates planned. The thematic probe into safeguarding practices concluded that people using the service felt safe and that staff had a good understanding of their role and were aware of policies and procedures. Ashbourne DS0000070317.V364063.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,22, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a warm, safe and comfortable environment for people whom use the service. EVIDENCE: The provider has begun a schedule of maintenance to improve the facilities at the home. The new manager has introduced a cleaning system that ensures that regular and emergency cleaning is undertaken within the home. Staff are aware of cross infection measures and have received appropriate training in relation to health & safety. People who use the service have good access to a range of communal areas that they appreciated. One resident was enjoying the private garden that has several areas of seating. The said that ‘it was good to have a lovely garden to sit in when the weather was fine’. The gardens are kept well maintained. The home is well equipped with aids to assist those residents with restricted mobility in the bathroom and toilet. The ground floor toilet needs to be fitted Ashbourne DS0000070317.V364063.R01.S.doc Version 5.2 Page 19 with a lock to ensure privacy. The use of paper towels is also recommended to minimise the risk of cross infection. Ashbourne DS0000070317.V364063.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. 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. Recruitment practices at the home protect people who use the service. There is a shortfall in training and this reflects on the quality of person centred care for people who use the service. EVIDENCE: Staff files were checked and contained all the required checks for staff. The provider has therefore met this requirement. A new member of the staff team spoken with during the inspection confirmed that all checks had been completed prior to them starting the job. They were presently undertaken their induction and awaiting additional training. They confirmed that they had completed all mandatory training with their previous employer and was waiting for them to send copies to Msaada. All staff spoken with could confirm their knowledge in relation to safeguarding and were well aware of the procedures. Training records were limited for all staff which therefore did not evidence training they have received at the home. There have been several changes in staffing at the home. The acting manager was in the process of reviewing what training staff had completed and drawing up a list of shortfalls. Staffing levels have increased with a deputy manager being employed. On three days a week there are three members of staff on duty to provide direct care to people using the service. On other days a volunteer assist in the area. Ashbourne DS0000070317.V364063.R01.S.doc Version 5.2 Page 21 This is expected to meet the social and cultural needs of people using the service. Ashbourne DS0000070317.V364063.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service are safe but there is a need to continue the management improvements so that the service is run in their best interests. EVIDENCE: The new manager needs to make an application to become registered as the home is presently being run in breach of the Care Home Regulations. There is good evidence that the new manager has made improvements since their arrival. However due to a limited response by the provider in meeting the requirements made at the last key inspection prior to the managers appointment means that they have been unable to address all of them within the timescales. Where the manager has the responsibility of supporting people using the service with their finances there are acceptable systems in place. Each person Ashbourne DS0000070317.V364063.R01.S.doc Version 5.2 Page 23 has a separate record that records transactions. Receipts are kept to support the entries. The manager was able to demonstrate that Health and safety systems are in place and kept up to date. The manager’s recent experience with a safeguarding issue will be reflected across the services practices. More care will be taken to ensure that the assessment process identity’s whether the service can meet the person’s needs. Staff training in health & safety will look at their role and responsibility in relation to safeguarding. Ashbourne DS0000070317.V364063.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 2 1 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 X X 3 Ashbourne DS0000070317.V364063.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 OP1 Regulation 4 Requirement A copy of the service user guide and the statement of purpose setting out Ashbourne’s aims and objectives and the services and facilities on offer, must be given to each individual resident so that they have information to make an informed choice. This was part of a requirement made at the last inspection timescale of 15/12/07 not met Every resident must have a copy of their contract with Ashbourne to ensure they know the terms and conditions of their residency. Timescale of 15/12/07 not met. The provider must not admit any person to the home that is not within the registration categories to ensure they are able to meet their needs. Care plans must contain more detail so as to instruct staff in how resident’s specific needs are to be met. Timescale of 31/12/07 not met Care plans must be in place to promote resident’s health and welfare, and in particular DS0000070317.V364063.R01.S.doc Timescale for action 30/06/08 2. OP2 5 30/06/08 3. OP3 14 31/05/08 4. OP7 15 (1) 30/06/08 5. OP8 12 (1) 30/06/08 Ashbourne Version 5.2 Page 26 6. OP9 13 (2) 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. Timescale of 31/01/08 partially met. The provider must review the 31/08/08 site of the controlled drugs cabinet to ensure that they are safely stored and meet the new regulations that came into force in 2007. 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. 5. Refer to Standard OP7 OP10 OP10 OP11 OP14 Good Practice Recommendations Resident’s care plans should be reviewed monthly as recommended by the National Minimum Standards. It is strongly recommended that a privacy lock be fitted to the ground floor toilet to ensure privacy. 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. 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. The acting manager needs to make a timely application to become the registered manager. The provider needs to ensure that this is acted upon. This is to ensure that the home is not being run in breach of the regulations. DS0000070317.V364063.R01.S.doc Version 5.2 Page 27 6. 7. OP30 OP31 Ashbourne 8. OP33 9. OP33 10. OP36 A system for reviewing the quality of Ashbourne service and improving it (A Quality Assurance system) needs to be developed and put in place, and be available for inspection. The provider or their representative should visit the service on a monthly basis to carry out a formal Regulation 26 visit. Copies of the report of that visit should 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. The supervision should be undertaken as a minimum of six times a year. Ashbourne DS0000070317.V364063.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Ashbourne DS0000070317.V364063.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!