Inspection on 01/06/06 for Ashcott House

This inspection was carried out on 1st June 2006.

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 found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashcott House 03/11/05

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Paradise Lodge

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15 Bramble Close

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

CARE HOME ADULTS 18-65 Ashcott House 12 Tokio Road Ipswich Suffolk IP4 5BE Lead Inspector Jane Higham Key Unannounced Inspection 1st June 2006 14:20 Ashcott House DS0000064918.V298134.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 Ashcott House DS0000064918.V298134.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. Ashcott House DS0000064918.V298134.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashcott House Address 12 Tokio Road Ipswich Suffolk IP4 5BE 01473 710607 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) Alliance Home Care Limited Mrs Claire Elizabeth Collins Care Home 15 Category(ies) of Learning disability (15), Physical disability (2) registration, with number of places Ashcott House DS0000064918.V298134.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 3rd November 2005 Brief Description of the Service: Ashcott House is a service for adults with learning disabilities situated in a residential area to the east of Ipswich town centre. The home was first registered in 1986, and comprises two separate buildings (formerly known as Cotswold and Hillside) but latterly renamed Side A and Side B Ashcott House. Side A is a seven bedroomed bungalow, plus staff office. Side B is a twostorey house with six single bedrooms and one shared bedroom. The main office facilities are based in Side A, although both houses have sleeping-in facilities for staff. Both properties have their own bathrooms, toilets, and communal living areas including a lounge, kitchen / diner, conservatory, and laundry. The more physically dependent service users live in the bungalow, Side A. The garden is shared by all fifteen service users, and can be accessed directly from either property. The front of the property is mainly a car parking area, which provides off-road car parking for staff and visitors, and parking for the minibus. Ashcott House DS0000064918.V298134.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Unannounced Key Inspection of Ashcott House, a 15 bedded residential care home for adults with learning disabilities, owned and administered by Alliance Home Care Ltd and sited in a residential area of Ipswich, to the east of the town centre. The inspection was carried out on 01 June 2006 over a period of five and a half hours. The home was inspected against the National Minimum Standards: Care Homes for Adults and the Care Standards Act 2000. The National Minimum Standards and Care Homes Regulations 2001 are referred to throughout this report and any non-compliance identified. All key standards were assessed as part of this inspection. The Registered Manager was present at the time of the inspection and assisted with the inspection process. On the day of the inspection, the Area Manager was visiting the home for the purposes of carrying out a monthly quality assurance visit in compliance with Regulation 26 of the Care Homes Regulations 2001. The Inspector had the opportunity to talk to members of the resident group and staff members who were on duty. What the service does well: The home is to be commended on the quality of its Statement of Purpose and Service User Guide, which it has ensured, is available to all residents. These documents provide a detailed account of the services available at the home and would provide valuable information to any prospective resident and their advocate or family member. The home provides a good standard of accommodation and plans were well in hand for the redecoration of resident bedrooms where required. Residents are obviously encouraged to personalise their own rooms. The two different styles of accommodation, one house and one bungalow enables the more independent residents to live together and have a more active non-restrictive lifestyle. The service provides residents with a very homely and happy atmosphere and staff and residents have good relationships. Staff work well as a team and are confident in their roles and responsibilities. The home is well managed and residents feel secure in the knowledge that they are well supported. Residents are provided with a range of activities both within the home and via the local day services. Residents are also supported to take an annual holiday. Ashcott House DS0000064918.V298134.R01.S.doc Version 5.2 Page 6 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. Ashcott House DS0000064918.V298134.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 Ashcott House DS0000064918.V298134.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, 2, 4 and 5 The home provides prospective residents with sufficient information to assist them in making a decision as to whether they wish to live at the service. The needs of prospective service users are assessed prior to a placement being offered. EVIDENCE: As part of the inspection, the home was able to evidence that it has a detailed Statement of Purpose, which includes all the information as required by Schedule 1 of the Care Homes Regulations 2001. Combined with the Statement of Purpose is a Service User Guide, which provides information on the services and facilities available at the home. The home was able to evidence that a copy of the Service User Guide is provided to residents and retained in their bedrooms. Whilst no new service users had been admitted to the home for some time and therefore pre-admission assessments were not available for inspection, the Inspector was able to examine community care assessments carried out in July of last year when all residents were re-assessed as part of a review process in relation to their funding. These assessments evidenced that a detailed breakdown of individual care needs had been provided which gave a clear picture of the physical and emotional support required by each service user. Ashcott House DS0000064918.V298134.R01.S.doc Version 5.2 Page 9 The home was able to evidence, that two service users, selected by the inspector for the purposes of case tracking, had been provided with a placement contract, which set out the terms and conditions of residence. The inspector was informed by the Manager that placement contract were currently being revised and re-issued under the name of the new owners. The pre-admission assessment process allows prospective residents to visit the service on several occasions before making up their mind whether they wish to move in for a trial period. At the time of writing three service user surveys had been returned to the Commission. Two service users confirmed that they had received adequate information before moving into the home and one service user commented, “Yes – it’s the right home for me”. Ashcott House DS0000064918.V298134.R01.S.doc Version 5.2 Page 10 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, 8 and 9 Residents living at the home can expect to be provided with a plan of care which details their assessed needs and the level of support they require for those needs to be met. Service users are supported to enjoy an independent lifestyle on a risk-assessed basis. EVIDENCE: As part of the inspection process, the inspector examined the care plans for two service users selected for the purposes of case tracking. At the time of the inspection, residents care plans were being revised and transferred to a system using the template provided by the owning organisation. In the case of both residents a summary of assessed need had been provided which then “triggers” a “lifestyle plan”. Each Lifestyle Plan sets out the abilities of the individual in relation to activities of daily living. In the case of the two residents selected for the purposes of case tracking, areas of need identified included: mobility, healthy living and personal hygiene. The Lifestyle Plan provides a breakdown of the level of support required by each resident. Ashcott House DS0000064918.V298134.R01.S.doc Version 5.2 Page 11 The Inspector was advised by the Manager that initially when the service was taken over by the current owning organisation, no care plans were in place thus limited information with regard to the care needs of service users was put in place. The Lifestyle Plans for the two service users were somewhat limited in their content but they did provide information on the assessed needs of both service users. It is the intention of the manager to provide more detailed information in relation to assessed care needs as these documents are transferred over to the new care planning documentation. It was clear that the changing needs of residents had been documented (in the case of one resident this had been a decrease in mobility) but these changes had not been dated and a clear care plan review process was not in place. It was noted during the inspection, that one service user was identified as suffering from depression, but this had not been identified as a need and no care plan was available to evidence how they would be supported or how their mental health would be monitored. Another resident had recently returned to the home after undergoing major surgery and it was noted that no short-term care plan was in place in relation to postoperative care. The home was able to evidence that both residents, selected for the purposes of case tracking, had been provided with a detailed and current risk assessment for all activities of daily living where it was identified that a risk may exist. During the time spent at the home, the inspector was able to observe residents taking part in the daily life of the service. One service user in particular played an active role in the day-to-day running of the home, undertaking certain tasks and domestic chores. Ashcott House DS0000064918.V298134.R01.S.doc Version 5.2 Page 12 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, 13, 15, 16 and 17 Residents living at the home can expect to be offered a wide range of activities, which are appropriate to their needs, and to be supported to access local community facilities. EVIDENCE: On the day of the inspection, the home was able to evidence that service users are provided with a range of activities either via community day services or at the home itself. Service users attend a range of day services, which include local authority resource units, supported work projects such as “Growing Places”, drop in centres and a “Friday Group” at the local YMCA. During evenings and weekends service users attend various learning disability social groups and enjoy outings to the pub and cinema. Plans were underway to convert the two conservatories (one of each side of the home) into activity rooms. The three feedback cards received from service users indicated that only one felt that there were always activities available which they could take part in. On the day of the inspection, four service users had enjoyed a day at the annual Suffolk Show. Ashcott House DS0000064918.V298134.R01.S.doc Version 5.2 Page 13 All service users are supported to go on an annual holiday. At the time of the inspection, three service users had recently returned from a holiday in Majorca and in June another four service users were going to Italy. Service users, who did not wish to go abroad, were going on an activity holiday that had been arranged within the UK. Several residents were able to tell the inspector how much they had enjoyed their holiday and others how much they were looking forward to their forthcoming trips. The home evidenced that residents are supported to maintain relationships with family members. Several residents make regular visits to their own homes. A parent visiting at the time of the inspection reported that their family member made regular visits home but always looked forward to returning to Ashcott House. The home operates an equal opportunities policy which is included as part of the Service User Guide. Residents who are able play a role in the daily life of the home and participate in domestic chores. One service user assisted to make the beds of some residents who were unable. The Inspector observed the evening meal being served to residents on Side B of the home. A senior member of staff who was the designated staff member on that side of the house prepared this. Residents ate their meal together in the dining room and chatted about the events of the day. Meals are selected from a planned menu and feedback gained from service users confirmed that they enjoyed the meals provided. Three comment cards received from service users confirmed that they “always” enjoyed the meals provided. Training records confirmed that all staff involved in the preparation of resident meals are provided with basic food hygiene training. Kitchen areas on both houses were fit for purpose and a kitchen cleaning rota had been established to ensure that the kitchen equipment and environment was maintained to a satisfactory standard of cleanliness and hygiene. Ashcott House DS0000064918.V298134.R01.S.doc Version 5.2 Page 14 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, 20 Residents living at the home can expect that personal care is provided to each resident in a way they prefer and require and that their physical health needs are met by community health services. At the time of the inspection, the facilities used for the storage of medication were not appropriate. EVIDENCE: A selection of resident care plans examined for the purposes of case tracking evidenced that the needs of residents in relation to personal care issues are assessed and the appropriate levels of support provided. Areas of need in relation to personal care may include personal hygiene and undressing with dignity. As stated earlier in this report, Lifestyle Plans (care plans) were somewhat limited in their content but the transfer to the revised care planning documentation should offer a wider opportunity for residents preferences in relation to the way in which personal care is provided to be documented. Through the inspection process, the home was able to evidence that the physical and medical needs of residents are monitored and met. The care planning systems contained detailed information on all medical interventions and support received from community health services. The three comment cards received by the Commission from service users confirmed that the respondents felt that they received the medical support that they needed. Ashcott House DS0000064918.V298134.R01.S.doc Version 5.2 Page 15 As part of the inspection process, the inspector observed medication being administered to residents at 18.00 on Side A of the home. The senior member of care staff responsible for administering service user medication at that time had undertaken medication training provided by a local chemist. The home uses the monitored dosage blister pack system. Medication was administered to individual residents appropriately and the accompanying Medication Administration Records (MAR) charts were completed correctly. The Inspector noted that residents’ medication was stored in a padlocked kitchen cabinet. The Royal Pharmaceutical Guidelines for the Administration and Control of Medicines in Care Homes states that kitchen areas are not suitable for the storage of drugs as an appropriate temperature for storage cannot be maintained. Best practice would suggest that residents’ medication is stored in a fit for purpose facility, which complies with the Misuse of Drugs (Safe Custody) Regulations 1973. Ashcott House DS0000064918.V298134.R01.S.doc Version 5.2 Page 16 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 Residents can expect to be provided with sufficient information to enable them to make a complaint or raise any concerns they may have. The homes policies and procedures offer protection to residents against abuse. EVIDENCE: On the day of the inspection, the home was able to evidence that it has clear procedures on the recognition and reporting of suspected abuse. Since the previous inspection, the home has acquired an up to date copy of the local authority reporting procedure for the protection of vulnerable adults. Personnel records seen evidenced that care staff receive training on the recognition of abuse. The home was able to evidence that it has a clear complaints procedure, which contains all the relevant contact details for the Commission and is included as part of the Service User Guide. A copy of the Complaints Procedure was not displayed within the building. In order to ensure that the Complaints Procedure is accessible to all, good practice would suggest that a copy is displayed within the building. The three comment cards received by the Commission indicated that the respondents knew who to speak to if they were unhappy and two out the three knew how to make a complaint. Complaints received by the home are recorded on an Allied Care template. This documentation provides details of the content of the complaint, but it does not establish an audit trail of the investigation carried out, outcome reached, action taken and date of feedback to the complainant. Since the previous inspection, the Commission has received no complaints in relation to this service. Ashcott House DS0000064918.V298134.R01.S.doc Version 5.2 Page 17 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 - 30 Residents can expect to live in a home which is comfortable, well maintained, homely and appropriate to their assessed needs. EVIDENCE: Ashcott House comprises two separate buildings named Side A and Side B. Side A is a seven-bedroomed bungalow and accommodates more physically dependant service users. Side B is a two-storey building, able to accommodate eight residents, in six single bedrooms and one shared room. Both houses have their own kitchen, bathroom, toilet, dining and lounge facilities. Side A would not be appropriate for physically dependant residents, as it does not have any lift facilities. As part of the inspection process, the inspector carried out an environmental tour of all accommodation, accompanied by the registered manager. The owning organisation continues with its programme of redecoration and replacement of dated furniture. All bedroom accommodation was furnished comfortably and in general maintained to a good standard of decorative order and repair. One service user bedroom was due to be redecorated whilst the occupant was away on holiday. Ashcott House DS0000064918.V298134.R01.S.doc Version 5.2 Page 18 In the majority of cases bedrooms had been made to look very personal with the addition of personal belongings, which reflected the tastes and interests of the occupants. Several residents had bought their own televisions, DVD players and hi-fi systems. Two bedrooms were noted to be without carpeting, although this was for hygiene reasons. Best practice would suggest that if at any time these rooms are vacated by the current occupants then new carpeting is provided. A requirement was made at the previous inspection for the owning organisation to review the door locks fitted to the doors of resident rooms as there was a concern that residents could double lock the doors from the inside thus barring entry by care staff in the case of an emergency. Since the inspection, the locks on the doors of resident rooms have been disabled and thus the majority of bedroom doors remain unlocked and the occupant is now unable to lock their door from the inside to ensure privacy. In order to protect the privacy of residents, the owning organisation must fit appropriate door locks, which are lockable from the inside, by way of a “privacy lock” but access can be gained by staff members in the case of an emergency. It was also noted that none of the service user rooms provided lockable storage facilities for residents to store personal or valuable items. Communal lounge facilities were very pleasant, furnished comfortably and provided a very homely environment in which residents could socialise. Each house also has a large conservatory, which at the time of the inspection were being converted into a sensory room and activity room for the use of residents. Whilst only one bedroom had the advantage of ensuite facilities, the home had appropriate communal bathrooms and toilets. Each house has its own laundry room and good infection control procedures were followed with the use of red dissolvable bags for soiled linen and clothing. The property stands in very attractive gardens, which includes an ornamental pond and a memorial garden for a past resident. All areas of the home were maintained to a good standard of hygiene and cleanliness and no unpleasant odours were detected. Ashcott House DS0000064918.V298134.R01.S.doc Version 5.2 Page 19 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, 33, 34, 35 and 36 Due to recent cutbacks, it was not possible to confirm whether a sufficient staffing level is provided to meet the needs of current residents. Service Users can expect to be supported by staff members who are both competent and who receive appropriate training to carry out their roles and responsibilities. EVIDENCE: On 24 April 2006, the Commission received notification that the home had cut its staffing level during the waking day from four members of care staff to three. The reason for this cutback is stated as the reduction in funding from social care services. During the inspection, the Manager expressed concern about this current reduction in staffing and the difficulty it was causing in sufficiently meeting the needs and ensuring the safety of residents. The decrease in staffing has meant that during the day two members of care staff are on duty on Side A and only one member of staff is on duty on Side B. The responsibilities of care staff are varied and include not only direct care to residents but also meal provision and general cleaning tasks. Of particular concern is the fact that as meals are provided by a staff member on both Side A and Side B, this leaves only one staff member to provide direct care for residents accommodated in both houses. Ashcott House DS0000064918.V298134.R01.S.doc Version 5.2 Page 20 Discussions with service users did not indicate that they had felt any real effect of the staffing cuts. The three feedback forms received indicated that respondents felt that they received the care they needed, were listened to by staff and that staff were always available when needed. The home needs to review the staffing levels currently offered and ensure that the individual social, emotional and physical needs of service users are met. The home was able to evidence that it had robust recruitment procedures and that references and POVA checks were obtained prior to any prospective staff member commencing duties. Personnel records seen evidenced that newly employed staff members were provided with a structured induction training programme. One new member of staff was currently undertaking the Learning Disability Awareness Framework Induction package. Records seen evidenced that staff are provided with the appropriate training to carry out their roles and that all senior staff undertake First Aid and medication training. At the time of the inspection, 6ix out of 13 staff members had completed NVQ qualifications. Personnel records seen confirmed that members of the care staff were provided with formal supervision on a regular basis. Staff were observed to interact well with residents, who advised the Inspector that they found staff members very helpful and that they were treated very well. Ashcott House DS0000064918.V298134.R01.S.doc Version 5.2 Page 21 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 and 42 Residents can expect to live in a home, which is effectively managed and administered with their best interests to the fore. Policies and practices are in place, which protect the safety and welfare of service users. EVIDENCE: The home is effectively managed by the Registered Manager who has been in post for approximately two years and has latterly achieved the Registered Manager’s Award. Since the recent staffing cutback, the Manager has had to devote more time providing direct care to residents and less time on managerial and administrative duties. This situation has been further compounded by the departure of the Deputy Manager who is not to be replaced for the foreseeable future. On the day of the inspection, the Area Manager was visiting the home for the purposes of carrying out a Regulation 26 quality assurance-monitoring visit. Reports of such visits are submitted to the Commission and contain feedback from both service users and staff as to the quality of the services provided. Ashcott House DS0000064918.V298134.R01.S.doc Version 5.2 Page 22 As stated earlier in the report, risk assessments were in place for all residents and where appropriate moving and handling assessments had also been completed. As part of the inspection, fire records were examined, which evidenced that fire alarm systems were tested on a weekly basis. However, two recording systems appeared to be in use and therefore the recording system was somewhat confusing. The home has been provided with a new recording system and therefore this one alone should be used. It was positive to note that all senior care staff had completed first aid training and therefore there was always a qualified first aider on duty. Ashcott House DS0000064918.V298134.R01.S.doc Version 5.2 Page 23 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 4 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 2 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 x 32 3 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 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 3 x 3 x x 2 x Ashcott House DS0000064918.V298134.R01.S.doc Version 5.2 Page 24 NO Are there any outstanding requirements from the last inspection? 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 YA6 Regulation 15(2)(b) Requirement The Responsible Persons must ensure that the care plans of residents are reviewed on a regular basis and that evidence is available to confirm that these reviews have taken place. The Responsible Persons must ensure that storage facilities for the safekeeping of residents medication is fit for purpose and complies with the Royal Pharmaceutical Guidelines. The Responsible Persons must ensure that a log of received complaints is maintained to provide a clear audit trail of the investigation carried out and outcomes reached. The Responsible Persons must ensure that the door to any resident bedroom is fitted with an appropriate privacy lock, which is lockable from the inside but accessible from the outside by home’s staff in the case of an emergency. The Responsible Persons must review the current staffing level to ensure that the health and safety of residents is protected DS0000064918.V298134.R01.S.doc Timescale for action 10/07/06 2 YA20 13(2) 10/07/06 3 YA22 Sch.4.11 10/07/06 4 YA26 12(4)(a) 31/07/06 5 YA33 18(1)(a) 10/07/06 Ashcott House Version 5.2 Page 25 and their individual care needs are being appropriately met. A report of finding must be provided to the Commission. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 6 7 8 Refer to Standard YA6 YA22 YA42 Good Practice Recommendations The Responsible Persons should ensure that resident care plans contain information about individual preferences and choices made. The Responsible Persons should ensure that a copy of the complaints procedure is displayed within the building and therefore accessible by all visitors to the home. The Responsible Persons should ensure that only one recording system is used for the testing of fire alarms and other fire safety equipment. Ashcott House DS0000064918.V298134.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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. 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