Inspection on 08/06/07 for Ashbourne House

This inspection was carried out on 8th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ashbourne House 06/05/06

Ashbourne House 07/02/06

Ashbourne House 03/10/05

Ashbourne House 23/03/05

Ashbourne House 15/06/04

Similar services:

Chirnside House

Keer Sands Residential Home

SignHealth

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

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

CARE HOMES FOR OLDER PEOPLE Ashbourne House 230 Lees New Road Oldham Lancashire OL4 5PP Lead Inspector Michelle Haller Unannounced Inspection 8th June 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ashbourne House DS0000005486.V339680.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 House DS0000005486.V339680.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashbourne House Address 230 Lees New Road Oldham Lancashire OL4 5PP 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) 01616241013 0161 665 2413 Werneth Lodge Limited Michelle Maylor Care Home 35 Category(ies) of Dementia - over 65 years of age (18), Old age, registration, with number not falling within any other category (17), of places Physical disability over 65 years of age (4), Sensory impairment (4) Ashbourne House DS0000005486.V339680.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 35 service users to include:*up to 17 services users in the category of OP (old age not falling within any other category). *up to 18 services users in the category of DE(E) (dementia over 65 years of age). *up to 4 service users in the category of PD(E) (physical disability over 65 years of age). *up to 4 service users in the category of SI(E) (sensory impairment over 65 years of age). 3rd October 2006 Date of last inspection Brief Description of the Service: Ashbourne House is a large detached property, set in it’s own grounds, located on the outskirts of Lees, approximately three miles from Oldham town centre. The home is registered to accommodate up to 35 people aged 65 years or above. The majority of rooms are single and have en-suite facilities. The home has three lounges a dining room and a room used for functions. Werneth Lodge Ltd owns the home. The charges are £338.00 to £345.26. The previous CSCI inspection report is available in the lobby of the building. Ashbourne House DS0000005486.V339680.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a key inspection for Ashbourne House which included a site visit to the home. The inspection took place unannounced, this means the manager did not know beforehand of the inspection date. In the course of the inspection 6 service users files and other records concerning the support and care of service users were examined fully, and the current daily records for all people living in the home were read through. Policies, procedures and other documents concerning the running of the home were also assessed. Six people living in the home were interviewed and one service users representative and two members of staff were interviewed. The interactions between service users, their representatives and staff were also observed over lunch, during organised activities and in the course of walking about the property. A tour of the private and communal areas of the building was also undertaken. Two CSCI service user questionnaires were also returned, and information received from social services and members of the public was also used as a basis for this inspection. The manager had completed information we requested and sent it back to us before we visited. We looked at this information and checked some of it out on this visit. What the service does well: The overall impression of the home is that the standard of support continues to improvement and the atmosphere is reported to be relaxed and welcoming. People are benefiting from the active involvement of the manager and owners in the home. The manager makes sure that information about the health and emotional needs of people is available prior to their admission. The manager has developed a good rapport with people receiving care and support at the time of the inspection. Routine health care and checks are made available to service users, and specialist care is provided to a satisfactory level. Ashbourne House DS0000005486.V339680.R01.S.doc Version 5.2 Page 6 Safety checks such as routine fire safety checks and equipment maintenance are carried out in the home. The owners and the manager do what the Commission For Social Care Inspection asks them to do. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Ashbourne House DS0000005486.V339680.R01.S.doc Version 5.2 Page 7 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 House DS0000005486.V339680.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 House DS0000005486.V339680.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessments undertaken ensure that service users and their representatives are confident that their needs can be met at Ashbourne Residential home. EVIDENCE: Service user files were examined included the most recent admission, the longest resident, the most frail service user and one other of the manager’s choice. All the files examined contained assessments that had been completed by the social worker or care manager prior to admission. The information provided was consistently detailed. The home’s admission check list and needs assessment provided detailed information about the service users physical, social and psychological needs. It Ashbourne House DS0000005486.V339680.R01.S.doc Version 5.2 Page 10 was apparent that the assessment process is ongoing, with certain aspects of support, such as social history and activities preferences, being updated in response to improvement or changes in needs. The assessments for the most recent admissions were detailed and provided a good picture of support needs. Each person is also allocated a key worker when admitted and those interviewed named the person allocated to them. Those who returned CSCI surveys confirmed that they were provided with sufficient information about the home before taking up residency. Comments included: ‘I was encouraged to visit the home before the move.’ And ‘He says he is settled here.’ Ashbourne House DS0000005486.V339680.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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health and personal care is provided on the principles of respect, dignity and choice, and based on individual need. EVIDENCE: The contents of reports and records concerning the wellbeing and welfare of service users living in the home demonstrated that staff were diligent and ensured that people received any health care required. Specialist health care including dental care, opticians and podiatry care, and visits to outpatient appointments were facilitated. Daily records for all people living in the home were examined and indicated that staff monitored and assessed the progress on a daily basis. Care plans and corresponding risk assessments, such as diet controlled diabetes and epilepsy care, had also been developed and were reviewed. Ashbourne House DS0000005486.V339680.R01.S.doc Version 5.2 Page 12 Pressure relieving equipment such as cushions were provided. Specialist health care monitoring continues to improve and people with a poor diet were weighed weekly. Correspondence and records confirmed that referrals to the continence service and district nurses were made when appropriate. People were observed wearing glasses, hearing aids and using walking aids such as sticks and Zimmer frames. Those at risk of falls are well monitored, with intervention put in place to promote health and reduce any risk. The people who were interviewed stated that the care and support they received had been discussed and agreed with them. Examination and observation of the homes medication routine confirmed that photographs people had been placed on the corresponding dosette boxes; sample signatures of all staff that administered medication had also been placed on the front of the Medication Administration records (MAR) file. Medication administered was signed for correctly. Those who self medicate are supported through a robust policy and these guidelines, including development of a risk assessment and guidelines were put in place. The medication guidelines were also revised to provide additional guidance for those who managed their own medication. In response to questioning about health care people commented -. ‘Staff are very nice- they look after you.’ And ‘If I feel unwell they get the doctor.’ And ‘I feel well looked after both day and night.’ Ashbourne House DS0000005486.V339680.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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Ashbourne House are able to make choices about their lifestyle and the social, cultural and recreational activities are in keeping with most people’s expectations. EVIDENCE: People who commented enjoyed the activities that took place at the home. Activity records confirmed that people participated in games such as ‘Connect 4’ game, floor puzzles, darts, and arts and crafts, themed film nights, manicure sessions, film nights and gardening. People also go out to pub lunches, shows, and museums and for walks to the local shop. Staff organise armchair exercises and the manager has also arranged for a qualified movement to music therapist to attend weekly. A session took place during the inspection and it was evident that people enjoyed this activity. One person commented ‘That were smashing a smashing exercise that.’ Ashbourne House DS0000005486.V339680.R01.S.doc Version 5.2 Page 14 There are photographs of people enjoying activities and past outings. Many people living at Ashbourne are supported in following their faith and a church service takes place once a month. Private Communion is also arranged for those who require it. The activities record further confirmed that a variety of activities were taking place and that people were been encouraged to participate and their responses noted. Throughout the day visitors were observed. The person interviewed stated that there were no restrictions to visiting and these could be private if necessary. Comments concerning visitors included:’ visitors are always made welcome and offered a drink- any time of day- doesn’t matter.’ Observations of the interaction between people, staff and others visiting the home confirmed that people were able to make choices about their lifestyle. Comments included: ‘You can do what want- stay in your room, sit out with the others- you have the feeling there’s always someone around to look out for you.- we have outing, go to a local pub for lunch- I don’t get bored- we have a meeting to discuss meals and what we’d like to happen. I enjoy gamesanything like that- play dominoes and Quizzes“ Another person comment about choice was ‘You can get up when you like and go to bed when you like.’ One person felt that the best thing about the home was ‘independence- they let you do what you want.’ Two staff members have been allocated to organise activities and support a residence meeting and notes of the meeting confirmed that people were encouraged to voice their improvement about improvements and changes. The training calendar includes the course ‘Activities for people living in a residential home’ provided by Age Concern. The activities co-ordinator will be enrolled on the next available place. People were also observed reading books and newspapers. . The dining room at Ashbourne provides a comfortable and clean dining experience. It was noted that all service users able to sit in this area at all meal times. The meals provided at Ashbourne House are evaluated through a computer programme that should ensure that they are nutritionally balanced. The midday meal on the day of inspection was steak casserole, potatoes and vegetables, followed by Manchester Tart. This meal was eaten by all and comments included ‘This is lovely- the meat is really tender.’ It was also clear from their actions that staff were aware of peoples dietary needs and preferences. Ashbourne House DS0000005486.V339680.R01.S.doc Version 5.2 Page 15 The teatime meal was to be tuna bake, and one person commented that this was one of her favourite meals. The store larder was well stocked with a variety of basic ingredients for home cooking. Fresh vegetables were also in store. The fridge and freezers were well stocked with meats, bread and vegetables. Fresh fruit juice, squashes, tea, coffee, cocoa and Horlicks were also readily available. The menu also indicated that meals were varied and culturally sensitive. A more detailed food intake chart was completed for people with reduced appetites and dietary supplements provided when needed. People were very enthusiastic about the meals provided in the home and confirmed that a choice was offered on daily basis and that food and snacks were varied and plentiful. Comments included: ‘The food is nice.’ And ‘Oh yes the foods very good- you want for nothing.’ Ashbourne House DS0000005486.V339680.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 and 18 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. There was some evidence that people knew who to complain to and felt that they would be listened to, however the manager does not fully treat all complaints brought to her attention as complaints, which potentially means that some people living at the home are not having their views taken seriously. EVIDENCE: Complaints and other records maintained by the home indicated that some complaints were recorded but the records failed to confirm whether they had been given serious consideration or the outcomes made known to the complainant. Since the last inspection it has come to light that the manager continues to be is uncertain about dealing with verbal complaints and when CSCI must be informed of complaints and allegations. This issue is discussed further under ‘Management’. People who were interviewed stated that they would discuss any concerns with a member of the care staff. Ashbourne House DS0000005486.V339680.R01.S.doc Version 5.2 Page 17 Two people said that they had made complaints that had been dealt with to their satisfaction. Comments from people using the service included; ‘I’ve no complaints but I would talk to the manager.’ And ‘Yes I definitely feel I would be taken seriously if I had any worries and at meetings they obviously take notice of what you’re saying.’ The homes adult protection policy and guidelines are detailed and in line with those developed by the local authority and investigations. One allegation concerning staff has been dealt with by the home appropriately. There is currently a safeguard investigation being undertaken by social services. The training records indicated that majority of staff have completed Protection of Vulnerable Adult training in the last year 2006- 2007. And those interviewed were clear and confident about their role in adult protection and highlighting abusive or potentially abusive actions or omissions. Ashbourne House DS0000005486.V339680.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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean and free from unpleasant odours and presents as a homely environment for the people living at the home. EVIDENCE: The inspection process included a tour of the communal and private areas. The home has recently been refurbished. During the tour it was observed that of the exterior of the building and grounds were well maintained. The garden areas were tidy and accessible to service users. The company employs a maintenance man and he carries out and arranges for maintenance of equipment and services as necessary. Ashbourne House DS0000005486.V339680.R01.S.doc Version 5.2 Page 19 All except one radiator had been made safe by being covered . The majority of bedrooms have en-suite facilities. In addition there are toilets, washbasins and specialist bathing facilities on each floor of the property. All the bedrooms entered were cosy and homely, people had been able to make them personal through putting up pictures and photos, ornaments and furniture from home was also in place. People who were interviewed were satisfied with their rooms, which had been personalised with their own belongings. People were observed moving freely and safely around the home both independently or using walking sticks, walking frames and handrails. The cleaning roster is in place- on the day of inspection the domestic staff was not on duty, however the rooms were clean and, in the main free from offensive odours, and most surfaces were clean and free from obvious stains. Staff were observed using infection control measures such as wearing aprons and washing hands before dealing with food. Ashbourne House DS0000005486.V339680.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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff at Ashbourne House are well -trained and supervised and are available in sufficient numbers to support people successfully and, enable the smooth running of the home. EVIDENCE: The staff roster has been revised to allow for four staff to be available over lunch, dinner and teatime. The staff compliment on the morning of the inspection was one manager; four care assistants and the cook, the domestic staff was off-duty. Examination of the roster indicated that this was the established staffing level. The atmosphere on the day of inspection was relaxed and unhurried. Staff were observed spending time sitting and conversing with people. It was also noted that staff were aware of those that needed attention and were prepared to intervene and provide effective emotional support spontaneously. The manager confirmed in information sent to the CSCI and through the training record that, since the last inspection, staff have completed the following training: manual handling, dementia care, infection control- including Ashbourne House DS0000005486.V339680.R01.S.doc Version 5.2 Page 21 Better Food, Better Business (provided by the Health and Safety regulators), National Vocational Qualification (NVQ) in care levels 2, 3 and 4 and a course entitled ‘Yesterday-Today-Tomorrow’. The observation of staff practice, discussion with staff and records made during supervision demonstrated that this training was having a positive effect on practice. Four staff files were examined and it was noted that a Criminal Record Bureaux Check (CRB) or POVA first checks had been sought, and two references and proof of identification was in place for each. Ashbourne House DS0000005486.V339680.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, and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of Ashbourne House aims to be open and respectful and has developed a quality assurance system for staff and people living at the home to contribute their views and influence how the home is run. EVIDENCE: The manager is completing the registered managers award, on the day of inspection the home appeared well managed. The manager continues to have problems around dealing with complaints. A complaints procedure is in place but the management team do not use it effectively, particularly in response to verbal complaints, which should be Ashbourne House DS0000005486.V339680.R01.S.doc Version 5.2 Page 23 formalised. There is a failure to formalise verbal complaints and therefore a written record of her response, and so complaints are not dealt with in a transparent manner. Because of this some people do not know whether their complaints have been taken seriously. Neither can the manager demonstrate that she has followed up issues in a professional manner. As previously mentioned recordings are at time scanty and do not give a full picture of the support people have received during the complaints process. The manager must provide complainants with written information about how their complaints will be investigated, the result of any investigation and how they can take their complaints further. These findings contradict the information provided by the manager in the Annual Quality Assurance Assessment returned to CSCI. It should also be noted, however, that people spoken to on the day of inspection felt that the manager was approachable and would listen to their point of view and their complaints. Furthermore CSCI surveys returned by people living in the home indicated that these people knew how to make a complaint and felt that the manager would listen to them. The manager must demonstrate that she fully understands the need to comply with Regulation 37 of the Care Standards Act- and be able to demonstrate that this has been done when asked to do so. The manager’s failure to use the homes complaints procedure has resulted in some people feeling that their complaints have not been acknowledged, taken seriously or investigated. This is cause for continued concern and the conduct of the manager in this area needs to be improved. Supervision records, discussion with staff, people living in the home and observations made during the inspection indicated that the service provided was adequately monitored. The improvement in the cleanliness of the home and general monitoring of the environment has been maintained and policies and procedures continue to be revised in response to the needs of people involved with the home. The contents of the last staff meeting was read through and the manager covered topics such as working as a team; gossiping; attendance and time keeping, staff appearance and manner of approach to people living at Ashbourne; improving the standard of personal care and grooming for service users including care of clothes and improving infection control. Staff were keen to comment that they felt that the general atmosphere in the home had improved. Comments from staff included ‘Staff moral has improved which makes the place happier, all the management is approachable, staff are Ashbourne House DS0000005486.V339680.R01.S.doc Version 5.2 Page 24 happier and feel more valued- a lot of work has gone on in the home. I feel listened to and my opinions and ideas get taken on board. At the last few residents meetings people have become more open.’ Comments from those who attended the residents meetings included ‘The meetings are worthwhile if you have something to say.’ Service users money are safeguarded as receipts for all transactions are maintained ensuring that the money spent can be tracked and verified. The owner audits the accounts every three months and mistakes are rectified, and the balances countersigned as correct. The manager needs to make sure that it easy to identify when money is being into or out of each persons account. In reference to health and safety the training plan confirmed that the manager recognises the need for additional staff to receive additional moving and handling and first aid training. The manager has completed accredited first aid training and records confirmed that some care staff had received training to update their practice and certificates. Radiator covers have been installed throughout the home. Records confirmed that gas and electrical appliances and services were regularly checked and maintained. Fire safety equipment was regularly checked and fire drills completed in accordance with guidance from the Fire Service. On the day of inspection the fire alarm was activated and it was noted that all the fire doors automatically closed. Ashbourne House DS0000005486.V339680.R01.S.doc Version 5.2 Page 25 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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Ashbourne House DS0000005486.V339680.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP29 Regulation 19 Requirement The manager must make sure that she checks out everyone she employs before the start at the home by doing POVA 1st checks and police checks. This will help to prevent anyone unsuitable from being employed at the home. Timescale for action 30/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP16 Good Practice Recommendations The manager should ensure that she can acts on all complaints including those made verbally. That she fully investigates them and that the complainant is treated with dignity, respect and discretion, while being supported through the process. This is to make sure that people feel able to voice their opinions without fear of reprisal or criticism, and also to demonstrate to others living at DS0000005486.V339680.R01.S.doc Version 5.2 Page 27 Ashbourne House Ashbourne House that complaints are dealt with in a professional manner. Ashbourne House DS0000005486.V339680.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 House DS0000005486.V339680.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!