Inspection on 29/05/07 for Ashcombe

This inspection was carried out on 29th May 2007.

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

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

CARE HOMES FOR OLDER PEOPLE Ashcombe Worting Road Basingstoke Hampshire RG21 8YU Lead Inspector Marilyn Lewis Unannounced Inspection 09:30 29th May 2007 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 Ashcombe DS0000069280.V336187.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. Ashcombe DS0000069280.V336187.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashcombe Address Worting Road Basingstoke Hampshire RG21 8YU 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) 01256 468252 01256 330988 Barchester Healthcare Homes Ltd vacant post Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33), Physical disability over 65 years of age of places (33) Ashcombe DS0000069280.V336187.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection New Service Brief Description of the Service: Ashcombe House is a care home providing nursing care that is owned and run by Barchester Healthcare Homes Ltd, an organisation that has another home in the locality. The home is situated in Basingstoke, close to shops and other amenities. Ashcombe House provides accommodation for thirty-three residents, in thirtyone single rooms and one shared room. Residents also have access to two lounges, a dining room and the small garden. The manager stated during the inspectors visit to the home that fees ranged from £513.50 to £950 depending on the level of care required. Ashcombe DS0000069280.V336187.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place on the 29th May 2007. The inspector toured the home and met with residents, visitors, a nurse, activities co-ordinator, carer, the cook and the manager. Records seen included three care plans and those for medication, complaints, staff training and recruitment and fire safety and drills. This is the first report for the home since it was registered with the commission in March 2007. Information received from residents, relatives and health professionals was taken into account when completing this report. What the service does well: The home looked clean and welcoming and residents said that they liked living there. Comments received included ‘there is friendly home environment’ and ‘the home cares for my relative very well’. Residents said that they felt safe when being assisted by staff and said that they were treated with respect at all times. Residents commented that ‘staff were lovely’ and ‘the staff are very good’. Residents said that they received good information about the home and were able to visit before making a decision to live there. No one is admitted to the home without a care needs assessment to ensure the home can meet their care needs. Staff follow the home’s clear procedures for dealing with medicines, which protects the health of the residents. Residents said that they could choose to participate in the programme of activities provided at the home. One resident said that she was able to do as she wished and was not told by staff what to do. Residents said that they enjoyed the choice of meals offered and staff supported residents who needed assistance in a friendly and sensitive manner. The home has robust procedures in place for the recruitment of staff that includes Criminal Record Bureau (CRB) and (Protection of Vulnerable Adults (POVA) checks being completed to ensure new staff are suitable to work with the residents. Ashcombe DS0000069280.V336187.R01.S.doc Version 5.2 Page 6 The manager has been employed since October 2006. She is a qualified nurse with experience in training and performance management. She has applied for registration with the commission. Residents said that they liked the manager and staff said that they received good support from her. It was evident during the visit that the manager has a good rapport with residents, visitors and staff. 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. 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. Ashcombe DS0000069280.V336187.R01.S.doc Version 5.2 Page 7 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 Ashcombe DS0000069280.V336187.R01.S.doc Version 5.2 Page 8 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, 3, 5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are given clear information about life at the home to assist them in making their decision about living there. The home does not provide intermediate care. EVIDENCE: The home has a Statement of Purpose and Service User Guide in place that provides prospective residents with good information about life at the home and includes the admission process. Records seen indicated that a care needs assessment is undertaken for all prospective residents. Assessments seen for three residents provided clear information on their care needs and their wishes, such as their preferred name. Ashcombe DS0000069280.V336187.R01.S.doc Version 5.2 Page 9 One assessment noted that the resident did not wish to be assisted by a male carer for personal care and this was followed through in their care plan. The manager said that prospective residents and their relatives were welcome to visit the home before admission. One resident spoken with said that she had visited the home before making a decision to move in and had been visited by the manager for assessment. Another resident said that her relatives had visited the home on her behalf and had discussed the home with her before her admission. Both residents said that they had been given the home’s Statement of Purpose and Service User Guide when visiting the home and had found the documents helpful. The manager stated on the information provided before the visit that she was arranging for the documents to be given to people on their initial enquiring and would not wait until they visited the home. The home admits residents for respite care but does not provide intermediate care. Ashcombe DS0000069280.V336187.R01.S.doc Version 5.2 Page 10 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. Residents feel they are treated with respect and they are protected by staff following the home’s clear procedures for dealing with medication. It would be in the best interests of the residents for them to be involved in the planning of their care. EVIDENCE: Information received from the manager stated that all the care plans had been updated to a newer format that would provide the information in a clearer style. Care plans were seen for the three residents being case tracked. The plans covered all aspects of care provision including communication, personal hygiene, nutrition and social needs. Details such as what clothing the resident liked to wear and their wishes for where they preferred to take meals were included in the plans. Two of the care plans showed evidence of monthly review but a care plan for one resident who had moved into the home and found it difficult to settle, had not been reviewed for two months. Although the plan had not been reviewed a Ashcombe DS0000069280.V336187.R01.S.doc Version 5.2 Page 11 staff member spoken with said that the care for the resident had been discussed during a team meeting. Another care plan stated that the resident wore glasses but then it recorded that glasses were not worn but did not give any reason for the change. The manager said that it was thought that the resident had not worn glasses but it had been written down in error originally. The care plans seen did not show evidence that the residents or their relatives, if appropriate, were involved in the review of the plans. Two residents spoken with knew that care plans were written but were not aware of what was written in them. Comments received from a relative prior to the visit stated that communication with the home regarding the care of her relative was good. A relative visiting at the time of the inspectors visit also said that communication with staff was good. The manager said that she was aware that some residents were not involved in their care planning and had spoken with staff to address this. Residents spoken with said that they asked staff to arrange a visit from their GP if they felt unwell and this was done. Although the information provided by the manager prior to the inspection indicated that one GP visited the home on a weekly basis and on request, the manager said that residents were able to keep their own GP if they wished and it was within that GPs area. Visits by GPs and other health professionals such as the optician and dentist were recorded in the residents care plans. However the care plans seen for one resident, who had been resident at the home for ten weeks, stated that the person should be seen by the chiropodist every six weeks but there was no indication that this had been arranged. The manager arranged for the chiropodist to visit the resident at their next consultation at the home. Comments received from a consultant psychiatrist who visited the home stated that the home was able to administer good basic nursing care. The nurse responsible for the administration of medication at the time of the visit went through the home’s procedures with the inspector. Systems were in place for recording all medication brought into the home and for the disposal of unused medicines. Medication records seen had been completed appropriately and medicines were stored safely. The majority of medicines are prescribed in blister pack format. The temperature of the fridge used for storing insulin was being monitored and recorded to ensure it was kept at the required temperature for the insulin. The GP signs to confirm which residents were to be given ‘homely medicines’ such as Paracetamol and Lactulose if needed. No controlled drugs were currently being held at the home but records seen of drugs previously administered had been completed correctly. There were no residents who were administering their own medication. Residents spoken with said that they preferred staff to be responsible for their medicines. Ashcombe DS0000069280.V336187.R01.S.doc Version 5.2 Page 12 Up to date information on medicines was available for staff. The nurse said that she had received training in the safe handling of medicines. Residents spoken with said that staff were very respectful and there were comments of ‘the carers are very good’ and ‘the staff are lovely’. During the visit staff were seen to knock on doors and wait before entering rooms and spoke with residents in a caring and friendly manner. One resident said that staff always closed the door of the room when personal care was being provided and she felt her privacy was respected. A screen was available in the shared room to allow for privacy when needed. Ashcombe DS0000069280.V336187.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. Residents’ views on the activities provided are taken into account when developing the activities programme. Residents enjoy the choice of meals provided. EVIDENCE: The home employs an activities co-ordinator who is responsible for the development of the activities programme. The co-ordinator has worked at the home for 17 years and had visited other homes in the area to discuss activities suitable for people in residential care. She said that she is also attending a workshop in London in June. The co-ordinator said that feedback she had received from residents indicated that they enjoyed quizzes and crosswords more than craftwork. This was confirmed when talking with residents. Entertainers such as musicians and singers visited the home on a monthly basis. Ashcombe DS0000069280.V336187.R01.S.doc Version 5.2 Page 14 Comments received from residents prior to the visit indicated that they would like the opportunity for more trips out and for an improved programme of activities on weekends. The manager and co-ordinator had started to address these issues. A minibus had been purchased by the organisation for the joint use of Ashcombe residents and the residents of another local home owned by the organisation. A trip had been arranged to Bournemouth and a BBQ had been organised for a weekend. The manager said that the activities programme was being developed further to provide additional activities. A resident said that she appreciated staff allowing her to make her own decisions as to whether to join in with group activities or to spend time quietly on her own. During the afternoon of the visit the co-ordinator held a quiz for residents in one of the lounges. The residents said that they had really enjoyed it. Some of the residents attended services at their local church and ministers visited some residents on a one to one basis. The manager said that one of the aims for the year was to improve the links with local clergy to enable a regular pastoral care service to be provided. Residents spoken with said that there were no restrictions on visiting and they were able to entertain their visitors in their room or in one of the communal areas. Two visitors spoken with said that they were able to visit at any time and that staff were always friendly and welcoming. One of the visitors said that they enjoyed being able to join their relative for lunch. It was evident during the visit that residents were able to exercise choice and control over their lives. Staff were heard to ask residents where they would like to sit and whether they wished to participate in the activities taking place. The staff respected the wishes of the residents. One resident said that staff ‘allow me to do what I want to do and do not tell me what to do’. All the comments received from residents and relatives said that the food provided at the home was good. Comments included the ‘food is excellent’ and ‘the food is very good and there is always a choice’. The cook said that she has information regarding the dietary needs of the residents and their likes and dislikes and she takes these into account when writing the menus. The menu for the day of the visit was a choice of homemade soup or brie parcels with redcurrant jelly followed by chicken in a herb sauce or lamb risotto with carrots, sweet corn and potatoes. Lemon cheesecake was the main desert. Supper was to be leak and potato pie or tuna mayonnaise sandwiches followed by strawberries and cream. Meals served at lunch were well presented and all residents spoken with said that they had enjoyed their meals. Residents were able to take their meals in the dining room, one of the lounges or in their own room if they preferred. Staff were observed supporting residents who needed assistance in a sensitive and friendly manner. Ashcombe DS0000069280.V336187.R01.S.doc Version 5.2 Page 15 Ashcombe DS0000069280.V336187.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 good. This judgement has been made using available evidence including a visit to this service. Residents and relatives feel that complaints will be taken seriously and any issues addressed. Residents are protected by staff awareness of the protection of vulnerable adults. EVIDENCE: Residents spoken with said that they would talk with the manager or one of the staff members if they had a complaint. The residents said that they felt the complaint would be taken seriously and acted upon. Relatives spoken with also said that they would speak with the manager if they had any concerns and feedback from relatives before the visit indicated that they felt any complaints would be acted upon. The home’s complaints procedures were included in the Statement of Purpose and Service User Guide that was given to each resident on admission. The manager said that there had been two complaints since the last inspection. The complaints were logged but the investigation and outcomes were not recorded. The manager said that one had been discussed with the complainant in a meeting and the other had been passed to the organisational manager, as it was to do with fees. The manager said that she would ensure the investigations and outcomes were recorded. Ashcombe DS0000069280.V336187.R01.S.doc Version 5.2 Page 17 Since the inspection visit the manager has notified the inspector that the responses, investigations and outcomes are recorded and kept in the file along with the initial complaint. The home has procedures in place for the prevention of abuse including Hampshire County Council’s Protection of Vulnerable Adults and a whistle blowing policy. Staff spoken said that they had received training in the prevention of abuse and were aware of the procedures to follow should abuse be suspected. Ashcombe DS0000069280.V336187.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, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Ashcombe House provides a clean and homely environment for all who live, visit and work there. Call alarms were not accessible to some residents sitting in their rooms, which could result in their care needs not being met as quickly as they would wish. EVIDENCE: The home is a detached property standing back from the road and is near to all the shops and amenities of Basingstoke. Accommodation is provided over two floors with stairs and a lift allowing access to each floor. Residents have access to a large lounge on the ground floor, a smaller lounge on the first floor plus the dining room. Offices for the administration staff and the manager are on the ground floor near the reception area. The manager said that a separate office for administration staff was being provided to enable the manager to Ashcombe DS0000069280.V336187.R01.S.doc Version 5.2 Page 19 have an office where she could meet with residents, relatives and staff in private. The home looked clean, welcoming and well maintained. In the last twelve months the home has recruited a maintenance manager to maintain and service the home. The manager said that an on going programme of improvement has provided an air conditioning unit on the first floor and the fire alarm and telephone systems have been replaced. Some carpets have also been replaced and six divan beds have been replaced by profiling beds that were more suitable for the residents and would minimise the risk of injury to staff. Residents are accommodated in 31 single rooms and one double room. Rooms seen looked clean and homely and contained many personal items such as television, photographs and ornaments. All residents spoken with said that they liked their rooms and one said that she had ‘ all she needed’. The home has a call alarm system fitted. While touring the home it was noticed that the call alarm that was in the room was not accessible to some residents who were sitting in their chairs so it was not possible for them to summon assistance should they require it. Some of the bedrooms are fitted with en-suite facilities and there are sufficient bathroom and toilets for residents. A new parker bath has recently been provided for one of the three assisted bathrooms. One of the bathrooms was being used to store wheelchairs at the time of the visit and this was causing a problem for a resident using the room. The manager said that the wheelchairs were not normally stored in the bathroom and she arranged for them to be removed. Staff said that they had the specialist equipment they required to support the residents including hoists and slide sheets. Protective clothing such as disposable aprons and gloves were readily available and staff were seen to use it as needed to minimise the risk of cross infection. During the visit some doors, where residents had asked that their door not be closed, were wedged open with small sandbags. The manager said that while automatic opening systems were being arranged, risk assessments had been completed for wedging the doors open to minimise the risk to residents should a fire occur. The risk assessments were seen to confirm this had been done. The laundry was located away from areas used by residents. Hand washing facilities were provided in the laundry. A small garden and patio area with seating is located in the front of the home alongside the car parking area. Ashcombe DS0000069280.V336187.R01.S.doc Version 5.2 Page 20 Ashcombe DS0000069280.V336187.R01.S.doc Version 5.2 Page 21 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. Residents feel safe when receiving assistance from staff and they are protected by the procedures used when new staff members are recruited. Staff training records were not up to date and this could result in some staff members not receiving the training they required to do their jobs. EVIDENCE: The manager said that staffing levels were more than sufficient to meet the needs of the residents. Two trained nurses and six carers were on duty in the morning and one nurse and five carers in the afternoon and evening. At night one nurse and three carers were on duty. The manager was also on duty during the day and she sometimes works evenings and weekends. Additional staff were employed for activities, administration, catering, domestic and maintenance duties. Staff spoken with said that they felt there were enough staff on duty and residents also said this. Ashcombe DS0000069280.V336187.R01.S.doc Version 5.2 Page 22 The home employs 10 trained nurses and 19 carers. Many of the carers trained as nurses in their home country and have been employed as NVQ level 3 carers. Fifteen of the carers hold NVQ level 2 or above which exceeds the 50 required. Two residents said that they felt staff had the skills to provide their care and they felt safe with them. The home has procedures in place for the recruitment of staff. Records were seen for three staff members who had commenced work at the home since the last inspection. Two of the files contained all the information required while the other one contained only one reference. The manager said that two references had been obtained but they were not available at the time of the visit. The manager said that she would ensure the references are placed in the records so that they are available during inspection visits. The files seen indicated that CRB and POVA checks had been completed. The manager said that a volunteer had been recruited to assist with activities but the person was not to start until the CRB had been obtained. The information provided by the manager prior to the inspection stated that an audit was to take place regarding staff training to identify their training needs and confirm training that has been attended. The audit had been completed by the time of the visit. From records seen it was not possible to confirm that some staff had received training in mandatory subjects such as moving and handling and the prevention of abuse. Staff spoken with said that they had received training and some had attended sessions relevant to the service group such as dementia care. The manager has informed the inspector that where training had not been fully recorded prior to July 2006, staff were undertaking further training in mandatory and regulatory areas and this was taking place on an ongoing basis. The home has employed an in-house trainer who was attending a four- day course in moving and handling in order to train staff at the home in manual handling. Ashcombe DS0000069280.V336187.R01.S.doc Version 5.2 Page 23 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, 32, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of the residents. The safe working practices in operation at the home protects the health and safety of residents and staff. EVIDENCE: The manager commenced work at the home in October 2006. She is a qualified nurse with experience in training and performance management. The manager is due to commence studying for the Registered Managers Award and has applied for registration with the commission. Ashcombe DS0000069280.V336187.R01.S.doc Version 5.2 Page 24 Residents and relatives said that they liked the manager and felt that she was running the home well. Staff said that they received good support from the manager and one staff member said that she was the best manager she had worked with. It was evident during the visit that the manager had a good rapport with the residents, visitors and staff. Meetings are held for residents monthly to provide an opportunity for them to voice their views on the quality of care provided at the home. Records were kept of the meetings and those seen indicated that a wide range of topics were discussed. Residents spoken with said that they found the meetings helpful. Relatives meetings are held on a three monthly basis. The manager said that she visits each resident on a daily basis and feedback from information gained during meetings is given on a one to one basis. Feedback was also given to relatives during one to one meetings. A resident survey was undertaken by the home at the end of 2006 and the information gained indicated that residents were satisfied with the quality of care provided. Survey questionnaires sent out by the commission resulted in completed forms being returned from five residents, five relatives, a nurse and a consultant psychiatrist. Overall the information indicated that the quality of care provided at the home was good. Comments included ‘it’s a friendly home environment’ and ‘the staff are very good’. There were comments regarding the difficulty with communication regarding some staff members from overseas and there was an example of staff not knowing the name of the food served, which posed a problem when the resident had impaired vision. Staff spoken with during the inspection were able to communicate well and residents said that they found they were able to talk with staff. This is an area that the manager needs to monitor. Staff meetings are held two monthly or more frequently if needed. The manager said that she was arranging for the meetings to occur more frequently to provide staff with regular group discussions. One staff member said that the meetings were interesting and information was provided on the discussions that took place at the meetings, for those staff members unable to attend. The manager said that she was in the process of developing a newsletter that would keep residents, relatives and staff up to date with any changes taking place at the home. The home has clear policies on the handling of residents’ money. No money is held at the home. Any expenses incurred such as hairdressing bills are invoiced to the resident or the person responsible for their financial affairs. Ashcombe DS0000069280.V336187.R01.S.doc Version 5.2 Page 25 Staff spoken with said that they received regular supervision. The manager said that she supervised the nurses who in turn supervised the carers, catering and housekeeping staff. Records seen did not make it possible to confirm that all staff had received supervision at least six times a year as required to ensure staff received feedback on their performance. The manager has said that process have been put in place to ensure that all staff receive supervision as required. During the tour of the home hazardous substances such as cleaning fluids were stored safely. The kitchen looked clean and was in good order with food stored appropriately. Health and safety notices were displayed around the home. Three monthly meetings were held for a team of staff who formed the Health and Safety committee. The team cascaded the home and organisational policies and procedures regarding health and safety to the staff. Fire records seen indicated that staff received fire safety training and attended fire drills. New procedures for the evacuation of the home using new equipment have been written and the manager said that further training was due to take place for all staff to be trained in the use of the equipment so that the risk to all who lived and worked at the home was minimised should an incident occur. Ashcombe DS0000069280.V336187.R01.S.doc Version 5.2 Page 26 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 3 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 3 17 x 18 3 3 3 3 2 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 3 2 x 3 Ashcombe DS0000069280.V336187.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? N/A STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 (2) Requirement Residents should be involved in their care planning to ensure their wishes are documented. Timescale for action 31/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ashcombe DS0000069280.V336187.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Ashcombe DS0000069280.V336187.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. 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