Inspection on 12/10/06 for Ashburnham Grove (75)

This inspection was carried out on 12th October 2006.

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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashburnham Grove (75) 08/02/08

Ashburnham Grove (75) 25/04/05

Ashburnham Grove (75) 20/09/04

Ashburnham Grove (75) 05/05/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Ashburnham Grove (75) 75 Ashburnham Grove Greenwich London SE10 8UJ Lead Inspector Ms Pauline Lambe Key Unannounced Inspection 12th October 2006 09:45 Ashburnham Grove (75) DS0000036887.V309073.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ashburnham Grove (75) DS0000036887.V309073.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ashburnham Grove (75) DS0000036887.V309073.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashburnham Grove (75) Address 75 Ashburnham Grove Greenwich London SE10 8UJ 020 8692 5032 020 8692 4301 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) Greenwich Council Vacant Care Home 11 Category(ies) of Learning disability (11) registration, with number of places Ashburnham Grove (75) DS0000036887.V309073.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Flats 1 and 2 are for residents who require long term care. Flat 3 is for residents who require respite care of no more than 6 weeks and two beds are retained for emergency admissions. 3rd August 2005 Date of last inspection Brief Description of the Service: Ashburnham Grove is a registered care home for eleven younger adults with a learning disability, who are residents of the London Borough of Greenwich. The registered provider for the service is Greenwich Council. The home is situated in West Greenwich, within a conservation area known as the Ashburnham triangle. The home is close to the centre of Greenwich, the station, park and Maritime Museum. The service accommodates seven permanent residents within two flats, and four short-term or respite service users in a separate flat on the first floor. All the bedrooms are for single occupancy. The respite and long stay residents live on separate floors and each has a designated staff team. The property has a separate flat to the rear of the building, which is occupied by a person supported to live independently. Greenwich Learning Disability pays the care fees with residents paying nominal fees for food, transport and rent. Residents pay privately for personal items such as toiletries and social outings. Ashburnham Grove (75) DS0000036887.V309073.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit for this unannounced inspection was completed on 12th October 2006 over 7 hours. The manager and staff participated with the inspection. One resident was in the home with others returning in the afternoon from the day centres. The home had six long stay and one respite resident at the time of this inspection. The service was last inspected on the 3rd August 2005. The inspection included a review of information held on the service file, a tour of the premises, inspection of records, talking to residents and the staff team and reviewing compliance with previous requirements. Comments cards were sent to residents prior to the inspection and following the inspection contact was made with relatives to get their views of the service. Relatives contacted said they had assisted residents to complete the comment cards and feedback received was generally positive. What the service does well: What has improved since the last inspection? What they could do better: The statement of purpose must be reviewed and updated. Foods with a shelf life must be dated when opened. Some improvements were needed to medicine management. Environmental issues noted in this report must be addressed. Staff rotas must show clearly who was on duty at any given time. Some improvements were needed to recruitment records to ensure they comply with regulation. The registered person must ensure the new manager applies to register with the Commission in due course. Ashburnham Grove (75) DS0000036887.V309073.R01.S.doc Version 5.2 Page 6 A number of policies and procedures must be reviewed and updated if needed. A system must be implemented to monitor hot water temperatures. This report includes some recommendations, which the registered person may wish to address. 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. Ashburnham Grove (75) DS0000036887.V309073.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashburnham Grove (75) DS0000036887.V309073.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to the service. A statement of purpose was provided but needed review to ensure it complied with regulation. Residents were admitted to the home based on a full assessment of need. EVIDENCE: The home had a statement of purpose and a copy of this was given to the inspector. This contained most but not all of the information required in schedule 1. The document must be updated to reflect the service provided and included all the information required. Requirement 1. Residents on the long stay unit had been in the home for many years. Residents admitted to the respite unit had assessments of need completed prior to admission. Ashburnham Grove (75) DS0000036887.V309073.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to the service. Care plans were well prepared and reflected resident needs. Efforts were made to ensure decisions made about resident care were in their best interest. Residents were supported to participate in activities based on risk assessment. EVIDENCE: Two care plans were viewed. These were well written in the first person, reflected the needs of the residents and showed how these were to be met. Care plans were reviewed regularly and included future goals. Relatives contacted said staff kept them involved in their residents care. Most of the residents were unable to fully participate in decision making. Staff worked with relatives to ensure resident’s needs were met and appropriate decisions were made on their behalf. Comments from relatives included ‘staff make decisions for my relative and I am happy for them to do so’. Risk assessments were in place in relation to resident participation in various activities. Again staff worked with relatives to ensure residents had Ashburnham Grove (75) DS0000036887.V309073.R01.S.doc Version 5.2 Page 10 opportunities for personal development and social opportunities based on risk assessment. Ashburnham Grove (75) DS0000036887.V309073.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 – 17. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to the service. Residents were supported to take part in age appropriate activities and to access local facilities. Contact with relatives and friends were encouraged and menus seen showed a varied diet was provided. EVIDENCE: Most of the residents attended day centres where they had opportunities for personal and social development. There were no plans in place for the current residents to seek paid employment. Residents had life plans, which reflected progress made and goals for future development. Residents were supported to take part in activities of choice and to access local facilities such as outings to the cinema, the pub, restaurants, hairdressing, local parks and to enjoy day trips and holidays. Staff worked with relatives to ensure they become familiar with residents choice and preferences and to have plans in place to meet these. Ashburnham Grove (75) DS0000036887.V309073.R01.S.doc Version 5.2 Page 12 As mentioned many relatives remained very involved with their resident’s life. Relatives said they were welcome to visit the home and some said their resident visited them at home on occasions. Relatives said that staff kept them informed of issues regarding their resident and involved them in their care. Since the last inspection the decision was made to provide respite care in the first floor flat. This service had its own manager and staff team and was developing its own identity. Relatives contacted gave positive feedback about the care provided when residents received respite care and the contact they had with the staff. Two beds in this flat were available to book for respite breaks and two were kept for emergency placements. Residents had their meals provided in their allocated flat. Kitchens seen were generally clean and tidy. Adequate food supplies were seen and records were kept for the fridge and freezer temperatures but not for food temperatures. Staff prepared menus with resident involvement where possible. Menus seen showed a varied and nutritious diet was provided. Residents were encouraged and supported to assist with cooking and clearing up where practical. Foods stored in the fridge in the respite flat had not been dated when open. Requirement 2 and recommendation 1. Ashburnham Grove (75) DS0000036887.V309073.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to the service. Resident’s personal and healthcare needs were met and stated in their individual care plans. Some improvements were needed to medicine management. EVIDENCE: Care plans seen showed how personal care needs were to be met. All bedrooms were for single occupancy, which provided privacy for residents. Staff were observed knocking on bedroom doors before entering. Personal care was given in private. All residents were registered with a GP, a dentist and had vision tests every two years. Residents visited a chiropodist as needed and staff provided some foot care. Other medical and specialist services were accessed via GP referral. Policies and procedures were provided in relation to medicine management. Since the last inspection staff had decided to store medicines in each flat. Medicines were inspected in one flat. These were stored appropriately, a record was kept for medicines received into the home, administered and returned to the pharmacist. Medication charts seen were well maintained and staff checked medicines at each handover. Medication records were checked for two residents and found to be correct. Some issues noted were that Ashburnham Grove (75) DS0000036887.V309073.R01.S.doc Version 5.2 Page 14 internal and external medicines were stored together, staff had decanted one medication from its original container and placed it in a different one and there was no thermometer in the medicine storage room. In the respite flat medicines were stored in the kitchen and again the temperature of this room was not monitored. None of the current residents managed their own medicines. The home did not keep a supply of homely remedies. Requirement 3. Ashburnham Grove (75) DS0000036887.V309073.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to the service. Adequate procedures were in place to manage complaints and adult protection. Relatives and residents indicated they knew how to make a complaint. EVIDENCE: A complaints policy and procedure was provided. Residents were provided with a copy of the procedure in a format with widget icons. Feedback from residents and relatives indicated they knew how to make a complaint and who to talk to if they had concerns. Since the last inspection three complaints were made about the respite service and six about the long stay service. Records seen showed complaints received had been managed appropriately. Neighbours had made a number of complaints about the long stay service. These were mainly in relation to noise made by residents. Staff had taken steps to address these. A copy of Greenwich adult protection procedures was provided. Any allegations or suspicions of abuse would be referred to the community learning disability team for investigation. No such issues were reported since the last inspection. Staff seen during the inspection had a good awareness of adult protection and how to handle such a situation. A number of staff had received training on adult protection since the last inspection. Ashburnham Grove (75) DS0000036887.V309073.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27 and 30. Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to the service. The home was generally well maintained and suited to meeting the needs of the residents. Some maintenance issues required attention and have been included in the text below and requirements. Residents and relatives did not raise concerns about the environment. EVIDENCE: Flat one had two bedrooms, a bathroom, lounge and a kitchen diner. One bedroom was viewed and the inspector was told plans were in place to redecorate this room. The bathroom was clean and tidy. Some tiles were missing from the surface near the bath and there was no lock on the bathroom door. Hot water temperature checked was within safe limits. Flat two had five bedrooms. Four rooms were occupied and one was vacant. The flat had a lounge/diner, kitchen, bathroom, shower room and toilet. The lounge had been redecorated and refurnished since the last inspection. Two bedrooms were viewed and found to be clean, tidy and personal. One bedroom door did not seem to close properly and this was brought to the attention of the manager. The bath and shower rooms were quite bare and clinical looking. Some toilet pans seen were very scaled and needed cleaning. Ashburnham Grove (75) DS0000036887.V309073.R01.S.doc Version 5.2 Page 17 There was no mirror in the bath or shower room. Hot water temperature checked was within safe limits. The respite flat on the first floor had four bedrooms. Only one was occupied. In bedroom 3 the paintwork by the washbasin needed to be renewed. The flat also had a lounge/diner, kitchen and bathroom. Hot water temperature checked was within safe limits. The ceiling over the window in the bathroom was damaged and needed repair and painting. In all flats there were small top windows in the bedrooms, which did not have any curtains or blinds fitted. This should be reviewed as it may disturb residents at night. The home was generally clean and tidy but some for the bathrooms did not have paper towels for hand washing. Some domestic hours were included in the staff team. Care staff supported residents to take part in domestic chores where practical. The home had a nice garden area to the rear. This was a bit overgrown and would benefit from being better managed and maintained so it provided a pleasant and relaxing area for residents to use. There was some parking available to the front of the property. The Commission have written separately to the registered person regarding the use of the flat to the rear of the property. Requirement 4 and recommendation 2. Ashburnham Grove (75) DS0000036887.V309073.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to the service. Staffing rotas kept could be made clearer. Some improvements were needed to staff recruitment records. Staff had access to relevant training. EVIDENCE: Staffing levels were based on resident needs and occupancy of flats. As mentioned the respite flat had designated staff. The night shift was covered with one waking person and one person sleeping in for the entire home. Rotas seen were difficult and could be made clearer. The manager said that staffing levels were adequate to meet the needs of the residents. Seven of the care staff had NVQ2 qualification or above with two care staff were currently completing the course. Once they have completed the course the home will have 50 of care staff with the qualification. Requirement 5. Staff were employed under Greenwich council recruitment procedures. Employee files were not kept in the home. A system was in place to keep relevant information on a card system. Two files were viewed, one contained the card with personal details but the second file did not have the card included. The card system did not show that all information required by regulation had been obtained for employee and this system must be reviewed and updated. For example the card did not provide evidence to show if there were any gaps in employment and if the person had been employed with Ashburnham Grove (75) DS0000036887.V309073.R01.S.doc Version 5.2 Page 19 vulnerable adults previously that a reference had been obtained from that employer. Requirement 6. Staff seen said they had access to training relevant to their role and received regular supervision. Since the last inspection staff had access to training such as learning disability and dementia, autism, moving & handling, fire safety, adult protection and challenging behaviour. Individual training records were not kept making it difficult to assess what training each employee had. The new manager planned to implement individual training records for staff. Recommendation 3. Ashburnham Grove (75) DS0000036887.V309073.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42. Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to the service. Attention was given to ensuring safety for residents and others. Efforts were made to hold meetings with residents and involve them in making decisions about the service. The home had a new manager in place since the last inspection. There was no quality assurance system in place. A number of policies and procedures required review. There was no system in place to monitor hot water temperatures. EVIDENCE: A new manager and deputy manager had started working in the home recently and had been transferred from another home within the organisation. Relatives raised some concern about the frequent staff changes in the home. The new manager had the skills and experience needed to fulfil her role but will need time to become familiar with the residents, the relatives, the staff team, the environment and the service provided. The registered person must ensure the new manager applies to register with the Commission. Relatives Ashburnham Grove (75) DS0000036887.V309073.R01.S.doc Version 5.2 Page 21 contacted were satisfied with the way the service was managed overall. Residents were unable to voice their opinion on this. Requirement 7. Residents meetings were held in each flat with efforts made to involve residents. A book was kept to record these sessions. Regulation 26 reports were sent to the Commission regularly. Staff meetings were held where resident care and management issues were discussed. An annual satisfaction questionnaire was sent to relatives and other interested parties. The manager said that there were plans in place to improve this review of the service and collate the information obtained. New performance indicators were being introduced and would give a better picture of the quality of the service provided in due course. Currently there was no recognised quality assurance system in place. Requirement 8. Many of the policies and procedures provided required review and updating to ensure they comply with regulation and current legislation. Requirement 9. From the records seen attention was given to ensuring the health and safety of residents and others. Safety records checked included fire safety, gas certificate and electricity supply. Fire drills were held at times to include day and night staff and fire risk assessments had been completed for all flats. There was no system in place to monitor the hot water outlet temperatures. This was an unmet requirement from the last inspection. Records were kept for accidents to residents and staff. The forms used to record accidents should be reviewed, as they may not comply with data protection. Requirement 10 and recommendation 4. Ashburnham Grove (75) DS0000036887.V309073.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 Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 2 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 2 X 2 X Ashburnham Grove (75) DS0000036887.V309073.R01.S.doc Version 5.2 Page 23 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 YA1 Regulation 4 Requirement Timescale for action 27/11/06 2. YA17 13 3. YA20 13 4. YA24 23 The registered person must provide a statement of purpose that complies with regulation and contains the information listed in Schedule 1. The document must also include changes to the respite service. A copy of the revised document must be sent to the Commission. The registered person must 27/11/06 ensure foods with a shelf life are dated when opened and stored according to the manufacturers guidance. The registered person must 27/11/06 ensure: • Internal and external medicines are stored separately • Staff must not remove medicines from their original dispensed container and put them in another container • The temperature of the rooms where medicines are stored must be monitored. The registered person must 27/11/06 ensure the premises are kept in DS0000036887.V309073.R01.S.doc Version 5.2 Ashburnham Grove (75) Page 24 5. YA32 17 6. YA34 19 7. 8. YA37 YA39 8 24 9. YA40 Appendix 1 a good state of repair internally and externally. • Bedroom doors must close properly to ensure fire safety. • The garden must be well maintained. • Toilet pans must be kept clean. • The bathroom door in flat one must have a lock fitted. • The missing tiles must be replaced in flat one bathroom. • Paper towels must be provided for staff to ensure they can practice infection control. • The ceiling in the respite flat bathroom must be repaired and painted. The registered person must ensure staff rotas kept provides details of staff on duty at all times in the home. Rotas must include the full name and designation of staff and the hours they worked. The registered person must ensure there is evidence to show that the information required by regulation 19 and schedule 4 is obtained prior to staff commencing work in the home. The registered person must ensure the home has a registered manager. The registered person must ensure that a system is in place to monitor and improve the quality of care provided in the home. The registered person must ensure that the homes policies and procedures are up to date and comply with current legislation. DS0000036887.V309073.R01.S.doc 27/11/06 27/11/06 27/11/06 27/11/06 27/11/06 Ashburnham Grove (75) Version 5.2 Page 25 10. YA42 13 The registered person must ensure that a system is in place to monitor the hot water temperatures. (Timescale of 14/10/05 was not met). 20/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA17 YA23 Good Practice Recommendations The registered person should monitor and maintain records of the temperature of food provided. The registered person should • provide mirrors in bath and shower rooms if this is assessed as appropriate. • make these rooms more homely and inviting. • provide curtaining on the top bedroom windows if this suits the residents. The registered person should maintain individual training records for staff. The registered person should review the accident forms used and ensure these comply with data protection. 3. 4. YA35 YA42 Ashburnham Grove (75) DS0000036887.V309073.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ashburnham Grove (75) DS0000036887.V309073.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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