Inspection on 21/11/06 for Ashcroft

This inspection was carried out on 21st November 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 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

Ashcroft 17/01/06

Ashcroft 04/07/05

Ashcroft 22/02/05

Ashcroft 10/10/04

Ashcroft 05/02/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Ashcroft 48/50 London Lane Bromley Kent BR1 4HE Lead Inspector David Lacey Unannounced Inspection 21st November 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ashcroft DS0000010126.V307731.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. Ashcroft DS0000010126.V307731.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashcroft Address 48/50 London Lane Bromley Kent BR1 4HE 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) 020 8460 0424 020 8402 5640 suemaloney@care-providers.co.uk www.care-providers.co.uk Care Providers (UK) Limited Mrs Stella Martine Barnes Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Ashcroft DS0000010126.V307731.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Staffing Notice issued 21 July 1999 Date of last inspection 17th January 2006 Brief Description of the Service: Ashcroft is an older, detached building, situated in a quiet residential area in Bromley. It is conveniently placed for public transport, and is near to local shops and other facilities. It is part of a family-run business, and the providers have another care home nearby and a separate domiciliary care agency. Ashcroft is registered to provide nursing care, which is provided over 24 hours with one nurse covering each shift. The registered manager is also a qualified nurse. The home provides accommodation on three floors, which can be reached via a passenger lift. Communal areas are on the ground floor. There is a garden at the rear, with a patio for use in good weather. Off road parking is available at the front. The providers plan to extend the care home at the rear of the property. Ashcroft DS0000010126.V307731.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection included an unannounced visit to the care home. The registered manager, deputy manager and members of staff on duty assisted with this. During my visit, I toured the premises, observed care practices, and examined documentation. I spoke with service users, visitors and staff members. I offered feedback at the end of my visit to the registered manager. What the service does well: What has improved since the last inspection? What they could do better: I have suggested three improvements: Ashcroft DS0000010126.V307731.R01.S.doc Version 5.2 Page 6 The home’s GP should be asked to review the homely remedies protocol regularly, at least once each year. The home’s whistle blowing policy could include direct reference to relevant legislation, so that staff may be assured there is legal protection for whistleblowers. Employers providing references for applicants who want to work in the home should be asked to use either their company-headed paper or add the company stamp to their written reference. 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. Ashcroft DS0000010126.V307731.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 Ashcroft DS0000010126.V307731.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users are assessed to ensure the home can meet their needs. The pre-admission assessments have enough detail to determine whether the home is able to meet the particular service user’s needs. Service users can make an informed choice about whether to move into the home. The home does not offer intermediate care, thus standard 6 does not apply in this instance. EVIDENCE: The home’s statement of purpose and service user guide meet standards and provide detailed information to help service users decide whether to move into the home. The registered manager undertakes the pre-admission assessments of prospective service users, and records the assessments on a form designed for the purpose. It was understood that another senior staff member from the provider group usually accompanies the manager during the assessment. The sample of pre-admission assessments seen during the inspection were Ashcroft DS0000010126.V307731.R01.S.doc Version 5.2 Page 9 comprehensive and included information from different sources, such as the service user, their family, and health and social care professionals involved in their care. Ashcroft DS0000010126.V307731.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. All service users have a care plan, based on assessment of their needs. Thus, staff have the necessary guidance to give effective care to service users. Service users’ health care needs are met, they are treated with respect and their privacy upheld. The administration of medication is managed well. EVIDENCE: Service users appeared well groomed, and were wearing suitable clothing for the time of year. Their hair was combed and clean, and service users who spoke with the inspector said the hairdresser visited regularly. A sample of service users’ plans was selected for inspection. These plans contained good evidence that service users’ health needs are assessed and reviewed regularly. Each file included a record of the service user’s weight, and risk assessments for mobility, falls, nutrition and pressure areas. Care plans had been drawn up, based on the assessments of the service users’ needs. Ashcroft DS0000010126.V307731.R01.S.doc Version 5.2 Page 11 Care plans had been regularly reviewed and updated. Daily records had been completed, with nurses and care assistants working together to ensure all relevant details were included. The registered manager audits care plans and pressure area care regularly. Wound care records seen were good, showing the progress of the wound. Where there was more than one wound for an individual service user, each wound had been documented separately, which addressed a previous recommendation in this respect. This meant it was possible to assess progress if one wound healed faster than another. The home has a GP, allocated under the local ‘visiting medical officer’ scheme. The GP visits the home each week and at other times as required. Service users said they were able to see the doctor if they needed. There were records of visits from other health and social care professionals, and it was pleasing to note there is a good working relationship with the local nursing homes’ liaison team. A monitored dosage system is used for medicines. Medication is stored in a locked medicine trolley or in appropriate cabinets in a locked clinical room on an upper floor. There is also a controlled drugs cabinet, though there were no controlled drugs in the home at the time of this inspection. Internal and external medications were being stored separately. The drugs refrigerator had insulin for a service user, labelled with the date of opening. The temperature of the fridge was being recorded daily. There was no oxygen stored in the home. Medicine administration was not witnessed on this occasion but the sample of medicine administration records seen showed these had been completed accurately. There were no service users self-administering their medicines. The records of a service user on digoxin included the pulse rate recordings taken by staff before giving this drug. Records of receipt and disposal of medicines were good. The home had a medication policy and procedures, a copy of the RPS (2003) guidelines for care homes, and a reasonably up to date BNF (March 2004). The registered manager audits medication administration regularly. The GP had last signed the homely remedies protocol in March 2005. It is recommended that the GP review this protocol at least once each year. Ashcroft DS0000010126.V307731.R01.S.doc Version 5.2 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Planned activities are available to service users, to engage in as they choose. All care staff have some involvement in facilitating activities. Service users choose how they spend their time and are supported to maintain contact with their families and friends. The menus are balanced and nutritious, and service users can choose what to eat. Service users are mainly satisfied with the food provided. EVIDENCE: Service users have access to different planned activities, and can choose whether to take part in these. All care staff are involved in facilitating activities, which include bingo, quizzes, singing, quizzes and reminiscence. Large print books are available. The notice board in the main hallway gave details of planned events for the next two months. These included a trip to a garden centre, two pantomimes, and entertainment from a magician. Service users can also have accompanied trips into Bromley over the Christmas period. Service users’ preferred lifestyles are respected. For example, discussions with service users and staff confirmed that service users can choose how they spend their time and can get up or retire to bed whatever time they wish. If a service user is not able to verbally communicate choices, staff use information Ashcroft DS0000010126.V307731.R01.S.doc Version 5.2 Page 13 gathered during the assessment process about that service user’s preferred routines. Service users can bring in their own personal possessions to make their bedrooms more personal and homely, and visitors are welcomed at any time. The food served at lunch was well presented and it was evident that service users had been able to choose what they ate. Carers were attentive, and offered sensitive assistance with feeding as required. They wore blue aprons during the lunch period. Most service users took their lunch at their chairs in the lounge, using individual tables. This seating arrangement did not encourage interaction between service users during lunchtime but it is understood the planned extension to the home should improve the dining facilities. The present dining arrangements also mean that condiments cannot be left for service users to help themselves as they wish but have to be taken around on a tray. There was one larger table being used by a group of three service users. The inspector joined this group, who made positive comments both about their lunch and also about the food served at the home in general. Two other service users who spoke with the inspector during lunch also said the food was good and that they could choose what they wanted to eat. Service users can opt to have an alternative to the main choice of meal and additional snacks or drinks are. If service users want to have a snack during the night, the kitchen is open and snacks are available. A record is kept of each service user’s main meals. The outcome of a recent food hygiene inspection of the kitchens is discussed below in the ‘Management and Administration’ section. Ashcroft DS0000010126.V307731.R01.S.doc Version 5.2 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users are given the information they need to be able to make a complaint. The care provider follows its procedures when investigating and responding to complaints. Service users are protected from abuse, and staff members have access to appropriate training about protecting vulnerable adults. EVIDENCE: A copy of the homes complaints procedure is displayed in the home’s entrance hall and a copy is also provided in the guide given to each service user. The timescales for response to complainants are appropriate and the procedure includes the CSCI’s local contact details. A relative who spoke with the inspector confirmed that the home took seriously any concerns or complaints raised and acted upon them. During the inspection visit, service users said they would speak to their relatives, a staff member or the manager if they were not happy about something. The home’s complaints file was seen and records had been kept of any complaints received, and the action taken in respect of those complaints. Since the previous inspection, three complaints had been received by the home but none made to the commission. The inspector saw examples throughout the day of positive, relaxed interactions between service users and staff. The home had a copy of the local Ashcroft DS0000010126.V307731.R01.S.doc Version 5.2 Page 15 authority adult protection guidelines, as well as site-specific policies and procedures. Staff receive relevant training in the protection of vulnerable adults, including how to recognise and different types of abuse. The inspector recommended the home’s whistle blowing policy be strengthened by direct reference to the Public Interest Disclosure Act, so that staff may be assured there is legal protection for whistleblowers. Ashcroft DS0000010126.V307731.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 26 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The premises provide a homely environment for service users, which is clean and safe. There is equipment to help service users maintain their independence. Procedures are in place to prevent infection and care staff have training in basic infection control practices. There are suitable sluicing and laundry facilities. EVIDENCE: The home appeared generally well maintained. It was clean, tidy, and there were no offensive odours. Potential hazards had been identified and their risks assessed. On the day of the visit, the heating was being kept at a comfortable temperature. The flooring in a communal WC near the lounge needed repair but, as this had already been noted and the manager was waiting for estimates for the work, the inspector has not made a requirement on this occasion. The provider employs a maintenance person to whom the staff report any items needing Ashcroft DS0000010126.V307731.R01.S.doc Version 5.2 Page 17 attention but it was understood this particular repair required the services of an external contractor. Most service users sit in the lounge on the ground floor. Space in this lounge is limited, especially at the ends of the room. The armchairs are very close together, so staff need to take care to avoid using poor lifting techniques when helping service users to move from their chairs. The seating arrangements are also commented on above in the section ‘Daily Life and Social Activities’, with regard to the dining facilities. Service users and staff will benefit if the planned extension to the home leads to improvements to the lounge seating arrangements. The bedrooms seen during the visit had both clocks and calendars. These are good orientation aids for any service users with confusion, especially as staff tick off the days on the calendars. The home’s laundry is sited in the basement. Its washing machines use the Otex system, which means there is no need to sluice at high temperatures. The laundry was well organised, with a full-time laundry assistant on duty during the week and a part-time assistant at the weekends. The linen cupboards on each floor were well stocked. The inspector examined several sheets and found them to be in good condition; the laundry assistants replace linen as needed. The hot water outlets tested during the inspection visit were at a satisfactory temperature. There are sufficient sluices and disinfectors in the home, and this equipment was in good order. Infection control procedures are in place and staff members receive relevant training. Equipment to assist service users to mobilise includes four hoists, two standing and two full body hoists. Grab rails are fitted in all corridors and toilets. Corridors are large enough for wheelchairs. Pressure-relieving mattresses and cushions were available to meet assessed needs. The emergency call system is readily accessible to service users and operates throughout the home. Some of the service users had bedrails and risk assessments were seen for these. The manager confirmed that padded sides are used with bedrails to enhance service users’ safety. The home has a passenger lift to access all floors. Some bedrooms that were formerly shared rooms had been converted into single rooms, but some shared rooms had been retained for those service users, such as couples, who prefer this arrangement. Building work for the planned extension at the back of the building had not started. The provider had submitted revised plans for which planning permission was being sought. Ashcroft DS0000010126.V307731.R01.S.doc Version 5.2 Page 18 Ashcroft DS0000010126.V307731.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Enough suitably qualified staff members are working in the home to enable effective care delivery to service users. Nurses hold current UK registration and, commendably, nearly all care staff have achieved at least NVQ level 2. Staff members have access to various other training opportunities that are relevant to their work in the home. The home’s recruitment procedures provide protection for its service users. EVIDENCE: On the day of the inspection visit, the number of staff working in the home and the skill mix of the staff members was appropriate to meet the needs of the 19 service users in residence. Although the home is registered for up to 22 service users, the manager said that changing some former shared bedrooms to single ones means that 19 is now the effective capacity. Staff members were seen to work well together as a team, and several confirmed there was usually a good team spirit in the home. Staff members said they thought there were enough staff and confirmed that agency staff were rarely used. Staff members often worked voluntary overtime to cover vacant shifts. It is important this is monitored to ensure staff do not become overtired and thus risk compromising standards of care. Staffing rotas seen showed that staffing levels and mix had been maintained, including staffing for cleaning, laundry and catering. There is a settled team with low turnover of staff. Ashcroft DS0000010126.V307731.R01.S.doc Version 5.2 Page 20 The inspector selected a sample of staff recruitment files for examination. As far as possible, these were files of staff members who were on duty during the inspector’s visit. The files showed that sound recruitment procedures were in operation and that all required information was obtained about applicants before they started work in the home. The authenticity of references would be enhanced by ensuring referees use either their company-headed paper or add their company stamp to the reference; this was not evident for all references in the files seen. CRB disclosures are stored separately, and each of the staff files had a corresponding disclosure in the separate CRB file. Staff members who spoke with the inspector confirmed they had applied and been interviewed for their posts. They had been required to provide references and have a CRB disclosure through the provider. The staff training records showed that staff continue with mandatory training after completing induction. The manager stated that all care staff are trained in first aid. Feedback during the inspection visit from staff members about the work they did and the on going support they received was positive. The inspector asked staff about specific areas, including service users’ care, health and safety, staff training and supervision. The staff possess a range of knowledge and skills, and had undertaken various types of training. Their training aimed to help them meet the totality of service users’ needs. For example, it was evident that some service users in the home suffer from dementia. The home continues to care for these service users, whose primary needs are physical rather than dementia. Although the physical nursing care needs are primary, staff members are also provided with dementia care training. The home has joined the Bromley training consortium and thus staff have access to their training events and opportunities. The provider has held Investor in People status since January 2006. Nearly all care staff have attained NVQ level 2, and some have either begun or completed NVQ level 3. Two new staff members are undertaking the NVQ 2 programme. As at the previous inspection, the home’s commitment to supporting its staff to attain NVQ’s in care is commended. Ashcroft DS0000010126.V307731.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The commission has assessed the manager’s fitness and she is registered as the manager of this care home. There is an open style of management, with staff, service users and relatives able to contribute their views about the running of the home. The provider supplies the CSCI with copies of the monthly visits to the home and there are other quality assurance strategies in place. The home promotes the health and safety of its service users, staff and visitors. EVIDENCE: The registered manager is a qualified nurse and is experienced in caring for older people. She holds relevant management qualifications and undertakes continuous professional development, which is required to maintain her registration with the Nursing and Midwifery Council. The manager is also an Ashcroft DS0000010126.V307731.R01.S.doc Version 5.2 Page 22 NVQ assessor, which enhances the home’s ability to ensure its care staff complete NVQ programmes. There were positive comments from service users and staff about the registered manager’s approach to managing the home. Service users said she was friendly and approachable, and they could talk with her at any time. A relative said she would address any issues raised. Staff said they were supported by their manager and were able to meet with her regularly. The next relatives’ meeting was due to take place on 30/11/06, and the agenda was displayed on the notice board in the home’s reception area. This notice board also had a copy of the last commission inspection report and a summary of the results of a satisfaction survey carried out by the home. There were other quality assurance strategies in place, including a quality management system covering service users’ care, information and care development, quality improvement and organisational fitness. Documentation from May 2005 and May 2006 was seen. Specific audits carried out regularly by the registered manager include food delivery, fire assessment, and accidents. The 2006 business plan for Care Providers Limited was also made available for inspection. The inspector examined a sample of records showing how service users’ money is managed. Monies are stored in a locked safe, in individual wallets, and each transaction had been clearly identified and signed for by two people. In each case, the amount of money held matched the recorded amount. Receipts had been retained, and receipts for deposits of money given to the service user or next of kin as appropriate. Service users are invoiced for additional charges, such as hairdressing or newspapers. A selection of health and safety documentation was examined and found to be up to date and within the appropriate timeframes. These included certificates for gas safety, portable appliance testing, and servicing of lifting equipment. The inspector saw staff using hoists correctly. A fire risk assessment had been completed, and fire extinguishers and emergency lighting had been checked and serviced appropriately. A recommendation from the previous inspection that staff do not allow any fire exits to become obstructed had been addressed. There was no evidence of such obstructions during this visit to the home. COSHH products in the cleaners’ cupboard on the top floor were being stored securely, together with a file of safety information about these products. An environmental health food hygiene inspection on 14/11/06 found “generally good standards of hygiene”. There were three requirements and six recommendations arising from this inspection, which the environmental health officer will follow up at a repeat visit. Ashcroft DS0000010126.V307731.R01.S.doc Version 5.2 Page 23 Ashcroft DS0000010126.V307731.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 3 X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Ashcroft DS0000010126.V307731.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 OP9 OP18 Good Practice Recommendations The registered person should ensure that the GP reviews the homely remedies protocol at least annually. The registered person should ensure that the home’s whistle blowing policy makes direct reference to the Public Interest Disclosure Act. The registered person should ensure referees use either their company-headed paper for references or add the company stamp to their written reference. 3 OP29 Ashcroft DS0000010126.V307731.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 Ashcroft DS0000010126.V307731.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!