CARE HOMES FOR OLDER PEOPLE
Ashcroft Ashcroft 1 Wiggie Lane Redhill Surrey RH1 2HJ Lead Inspector
Lisa Johnson Unannounced Inspection 3rd July 2006 02:00 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 DS0000013557.V302730.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 DS0000013557.V302730.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Ashcroft Address Ashcroft 1 Wiggie Lane Redhill Surrey RH1 2HJ 01737 789656 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) Mr Roopesh Ramful Mrs Aruna Devi Ramful Care Home 5 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (5) of places Ashcroft DS0000013557.V302730.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The total maximum number of persons to be accommodated must not exceed five Persons in the category (LD) Learning Disability must be aged over 40 years 27th April 2006 Date of last inspection Brief Description of the Service: Ashcroft is a semi-detached house situated in a residential area in Redhill Surrey and is close to local amenities. The service provides accommodation to five adults with learning disabilities. All the service users have single occupancy bedrooms, which are arranged over two floors. The home has a communal sitting room, separate dining room and large kitchen with a breakfast bar. There is a small garden to the rear of the house and parking is available at the front. The weekly fees range from £400-£500. Ashcroft DS0000013557.V302730.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the second key inspection carried out in the home The unannounced inspection was carried out over six and half-hours by Mrs. L Johnson and the establishment was represented by Mr. R Ramful. The focus of this inspection was to review requirements made at the last inspection and to look at all the required key standards. Care plans, policies and procedures and other required documents were sampled. The inspector spoke to three service users who live in the home to gain their views on the care provided. The inspector also spoke to two members of staff. The service users involved in discussion all commented positively towards the care they received at the home. However although the home has made some progress in responding to the previous requirements there are still some matters requiring action outstanding since the inspection 27th April 2006 and other matters needing immediate attention were identified as part of this inspection process. The inspector would like to thank the service users and staff for their hospitality and cooperation in carrying out this inspection. What the service does well:
The home provides a warm, relaxed and welcoming atmosphere. Service users are supported to maintain their independence in the home. During the inspection service users were observed to be laying the tables and another individual was observed to be putting his laundry in the washing machine. The inspector spoke to one service user who said, “ I like cleaning my room such as vacuuming and dusting”. Service users were observed making choices and were seen in the kitchen making themselves drinks. Two service users spoken to were happy with the support they received from staff . One individual who had recently moved into the home stated “ I was made to feel welcome I don’t feel like I am be cared for I feel more like member of a family”. Ashcroft DS0000013557.V302730.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection?
At the previous inspection a requirement was made that the homes statement of purpose and service user guide should be made available in the home and this has now been completed.’ All individual care plans have been reviewed and updated with photographs of individuals being available with their care plan. The home has made some improvements in respect of the medication administration practices in the home. The names of service users were recorded on their medication card. Improvement was seen in the recording and transcribing of written medication instructions on the medication administration card. The responsible individual has ceased the practice of secondary dispensing medications into medicos boxes and confirmed to the inspector that he has made arrangements for a different pharmacist to visit the home to look at the implementation of blister backs and to discuss staff training. The inspector was provided with written verification that this meeting was taking place a day after the inspection. The inspector was provided with written verification that two members of staff have been booked on to training on safeguarding adults and moving and handling. Since the inspection the responsible individual has confirmed that he has implemented a local safeguarding adult procedure. The rubbish in the back garden has been removed and the replacement of the light fitting in the bathroom was in progress. The inspector was provided with information that arrangements are in progress for the installation of the call bells in service users bedrooms, however this equipment needs to be ordered and installed. Improvement was seen in the recording of staff hours in the home. One person has applied for National Vocational Qualification training (Level 2) and arrangements are being made for another member of staff to make an application. At the previous inspection a requirement was made that updated police checks must be completed for two members of staff as their existing checks were from previous employers. The responsible individual confirmed that this has been completed. The responsible individual has submitted a written report to the Commission for Social Care Inspection outlining an incident that had not been immediately reported. During this inspection the accident and incident records were sampled which concluded that no further serious issues had occurred. The water temperature is now checked weekly with written records maintained.
Ashcroft DS0000013557.V302730.R01.S.doc Version 5.2 Page 7 The responsible individual confirmed he has contacted the water company in respect of legionalla testing but is waiting for them to visit. During a tour of the home the fire exit in the dining room was now clear of obstructions. A previous requirement was made that covers must be supplied on all radiators. The responsible individual has confirmed that an order has been made and that the home is awaiting delivery. The hot water is checked weekly and a written record is maintained. The responsible individual has obtained paper towel dispensers and liquid soap for hand washing which was provided in the bathrooms . What they could do better:
There are still some requirements made during the last inspection dated 27th April 2006 that have not been fully completed by the provider. The Commission has decided to give extended timescales for some of these requirements. A failure on the part of the provider to meet the requirements within the stated time frame may result in a statutory notice being served under regulation 43 of the Care Homes Regulations 2001 (as amended). A requirement was made that service users should sign to confirm their agreement of their individual plan. This is to ensure that service users are consulted and are fully involved in the care plan process. Occasional gaps were again found on medication administration cards, which does not confirm that service users have received their medication. This issue was highlighted to the responsible individual who stated that he had had brought this matter to the attention of all staff. However an immediate requirement was made that all staff who administer medication must sign the medication administration record to ensure that service users are protected by the homes medication policies and procedures. A further requirement was made that all staff who administer medication must receive updated training. The homes complaints procedure was seen on display in service users bedrooms, however some of the information must be updated. This is to ensure that service users are provided with the correct information if they wish to raise and concern. Although the home has made progress in booking two members of staff on to safeguarding adult and moving and handling training all care staff working in the home must attend this training. A further requirement was made that this matter is fully completed. The registered manager has still not attended the local authority multi-agency safeguarding adult training and a further
Ashcroft DS0000013557.V302730.R01.S.doc Version 5.2 Page 8 requirement was made that this should be completed to ensure that service users are protected from abuse. The inspector sampled the staff recruitment records and it was observed that a newly appointed member of staff didn’t have a second written reference on his personal file. The responsible individual showed the inspector evidence of a written note that he had recorded after obtaining a verbal reference and informed the inspector that he was still waiting for a second written reference to arrive. A requirement was made that staff should not commence employment in the home until all the required information is obtained. This is to ensure that service users are protected by the homes recruitment policies and procedures. The inspector was informed that arrangements are being made for the registered manager to recommence the registered mangers award in September 2006. A further requirement was made that the agreed start date is confirmed to the Commission for Social Care Inspection. This is to ensure that there is a qualified manager who has the appropriate knowledge and skills and who is able to support the service users living in the home. A previous requirement was made that the homes written policies and procedures were updated and this matter has not been completed and a further requirement was made to ensure that this is fully completed. From records sampled it was evident that formal staff supervision needs to be updated. A requirement was made that all staff receive formal supervision with the registered manager on a more regular basis at least six times a year.This is to ensure that staff have the skills and knowledge to support service users competently 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 DS0000013557.V302730.R01.S.doc Version 5.2 Page 9 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 DS0000013557.V302730.R01.S.doc Version 5.2 Page 10 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. The home is able to demonstrate that service users and their relatives are provided with adequate information so that they are able to make an informed choice about the suitability of the home as a place to live. The home is able to demonstrate that pre admission assessments are completed prior to admission to the home. The service does not support service users with intermediate care. EVIDENCE: The homes statement of purpose and service user guide available in the home. Since the previous inspection a new service had moved into the home recently on a respite care basis and this was an emergency admission. However it was seen that the home had been provided with an assessment completed by the local authority. It was further evidenced the home was completing its own assessment and were preparing a care plan. The inspector had the opportunity to speak to the service user concerned who said “ I have been
Ashcroft DS0000013557.V302730.R01.S.doc Version 5.2 Page 11 made welcome on my first day here and staff spent some time with me introducing me and providing me with information”. Ashcroft DS0000013557.V302730.R01.S.doc Version 5.2 Page 12 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): , 8, 9 & 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Further work is required in ensuring that service users and/or their representatives sign individual plans where possible to ensure that they are fully involved in the process. Further work is required to ensure that service users are protected by the homes medication policy and procedures. Service users privacy and dignity is respected. Improvements are necessary regarding outstanding requirements from the previous inspection. This area has been assessed as poor in view of the nature of the outstanding requirement for example medication, which has not been fully achieved. EVIDENCE: Since the previous inspection the home has made improvement in reviewing and updating all individual care plans and risk assessments and photographs of individuals were available with their records. However a requirement was made that service users should agree and sign their care plans to ensure to ensure that they are fully involved in the care plan process. Ashcroft DS0000013557.V302730.R01.S.doc Version 5.2 Page 13 Service users have access to a local GP and have annual checkups. Individuals receive chiropody and access dental services. Although records are maintained of these appointments, at the previous inspection it was recommended that the health screen checks should be stated in the care plan. This has not be completed and a further recommendation was made. Since the previous inspection the home has made some progress in improving the medication administration practices in the home. The names of service users were recorded on their medication card. Improvement was seen in the recording and transcribing of written medication instructions on the medication record. The responsible individual has ceased the practice of secondary dispensing medications into medidose boxes and confirmed to the inspector that he has made arrangements for a different pharmacist to visit the home to look at the implementation of blister backs and to discuss staff training. The inspector was provided with written verification that this meeting was taking place a day after the inspection and that arrangements were to be discussed to ensure that staff who administer medication receive up to date training. There were six occasions again when a member of staff did not sign for medication. The responsible individual informed the inspector that he has raised this matter to the staff reminding them of their responsibilities. However a further immediate requirement was made that all medication administered to service users must be signed by the member of staff and an audit trail should be implemented. This is to ensure that service uses are protected by the homes medication administration policies and procedures. All individuals living in the home have their own bedrooms and during the inspection the privacy of service users was respected. One person told the inspector he was offered a key to his room but chose not to use it. There were no restrictions and service users were observed to be moving freely around the home and were seen to be helping themselves to drinks and snacks in the kitchen. Service users have access to the telephone if they wish to make calls. Ashcroft DS0000013557.V302730.R01.S.doc Version 5.2 Page 14 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. The home is able to demonstrate that service users have access to a range of recreational and leisure activities and maintain links with their family/friends and the local community. Service users are supported to make choices and individual preferences are respected. Service users receive well-presented and balanced meals EVIDENCE: It was clear from observation that service users are supported to maintain their independence and are involved with household tasks. One individual told the inspector “I like to clean my room, I like to vacuum and dust”. Another individual was observed to be laying and clearing the tables for dinner and another service user was seen using the washing machine. Two service users like to go out independently and access the local community to undertake shopping and one individual works part time in a shop. The inspector spoke to a new service user in the home who likes reading and said that staff have been supporting him to go to the local library. All service users possessed their own televisions and music centres and one individual showed the inspector his collection of videos. The home provides occasional outings and service users and staff are currently discussing plans about their annual holiday.
Ashcroft DS0000013557.V302730.R01.S.doc Version 5.2 Page 15 Service users maintain links with relatives and friends. One person maintains links by letter and telephone and another service user has a friend who accompanies him to church. Service users were happy with the meals provided and choices are accommodated. One service user said, “The staff know what we like”. The evening meal was well balanced and nutritious. Service users are able to help themselves to drinks and one person asked for some toast in the evening which was accommodated. Ashcroft DS0000013557.V302730.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure but this needs to be updated to ensure that service users and relatives have the appropriate information should they wish to raise a concern. Improvement in staff training is needed to ensure that residents are protected from abuse. EVIDENCE: There is an accessible complaints procedure in place, which was seen in the service user guide and on display in individual’s bedrooms. However some of the information in the procedure in service users rooms was out of date. A further requirement was made that this procedure is reviewed and updated. This is to ensure that service users have the correct information should they wish to raise a concern and that their complaint will be listened to. Service users spoken to spoke positively about the care in they receive. One individual stated, “The staff are caring and they have made me feel welcome, I don’t feel like I am being cared for I feel part of a family”. Another individual commented positively about the support he receives from the responsible individual and registered manager. At the previous inspection a requirement was made that all care staff must receive up to date training in safeguarding adults. The inspector was provided with evidence that two staff have been booked on training. However it is further required that all staff working in the home should complete this training
Ashcroft DS0000013557.V302730.R01.S.doc Version 5.2 Page 17 and that the registered manager should attend the local authority multiagency safeguarding adult training. This is to ensure that that staff receive the appropriate knowledge and information to protect service users from abuse. Ashcroft DS0000013557.V302730.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well maintained. Service users bedrooms were viewed as comfortable. Call bells need to be installed to ensure that service users have the specialist equipment they require to maintain their independence. The home is clean and hygienic ensuring that service users have a pleasant home to live in. EVIDENCE: The home is based close to Redhill town centre. The service provides a homely atmosphere and was well maintained and furnished. There is small garden to the rear of the house. Service users have their own bedrooms which were pleasantly furnished and individually personalised. Service users were observed to a wide range of personal belongings in their room including televisions, videos and music centres. Service users are provided with keys if they wish to use them.
Ashcroft DS0000013557.V302730.R01.S.doc Version 5.2 Page 19 At the previous inspection a requirement was made that call bells should be installed in the bedrooms and bathrooms. The responsible individual informed the inspector that he is in the process of acquiring information. However a further requirement was made that the call bells should be installed to ensure that service users have the specialist equipment they require to maximise their independence. The home was cleaned to a good standard and was hygienic and appropriate hand washing facilities were now in place. A separate laundry room is available to the rear of the house. Staff training records confirmed that staff have received training in infection control. Ashcroft DS0000013557.V302730.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staffing levels were sufficient to meet the needs of service users. Further work is needed to ensure that at least fifty percent of staff obtain National Vocational Qualifications. Further work is needed in respect of the homes recruitment and practices to protect service users. Two training matters need further action to ensure the health, welfare and safety of service users is protected and that staff have the appropriate skills to provide support. EVIDENCE: There are currently four service users living in the home although one individual is staying on a temporary basis. Improvements have been made in the recording of the duty rota. The home now employs six staff including the responsible individual and the registered manager. The rota indicates indicates that two staff work on the morning shift. Sometimes there is also another staff member working from nine to five and one member of staff works in the afternoon shift. The home provides a sleep in staff member at nighttime with the responsible individual being on call. It is strongly recommended that the registered manager review the present staffing level if the service capacity increases. A previous requirement was made that fifty percent of staff must obtain National Vocational Qualifications (Level 2). Since the previous inspection one
Ashcroft DS0000013557.V302730.R01.S.doc Version 5.2 Page 21 member of staff has enrolled to undertake the course and another part time staff member has applied to do the course, which he will be completing through his other care employment. A further requirement was made that this matter is achieved to ensure that service users are supported by appropriately qualified staff. A new member of staff has commenced employment in the home and recruitment records were sampled. The inspector was informed that a POVA first check was completed and an enhanced police check was applied for. However there was only one written reference on file and the inspector was informed that the home was still waiting for receipt of the second reference. The responsible individual had gained a verbal reference which he had kept notes of. A requirement was made that the second written reference for this individual should be obtained and that new staff should not be employed until this information is obtained. This is to ensure that the welfare and safety of service users is protected by the homes recruitment policies and procedures. Staff training records were sampled and it was evident that new staff receive induction, which was confirmed by one member of staff spoken to. Mandatory training was recorded. A previous requirement was made that all care staff must receive training in safeguarding adults and moving and handling. The responsible individual provided the inspector with verification that two staff are attending safeguarding adult training in July 2006 and two staff are booked to attend moving and handling in September 2006. A further requirement was made that all staff are provided with dates to attend these courses to ensure that staff have the appropriate knowledge and skills to protect the health, welfare and safety of service users. Ashcroft DS0000013557.V302730.R01.S.doc Version 5.2 Page 22 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 36 & 38 Quality in this outcome area is Poor. This judgement has been made using available evidence including a visit to this service. The registered manager requires additional training to ensure that she has the knowledge and skills to support the needs of service users living in the home. Staff must receive regular formal supervision to ensure they are competent to carry out their role and policies and procedures need updating. The home is able to demonstrate that quality assurance systems have been implemented. The financial interests of service users are protected. One health and safety issue requires action. To ensure that the home is run in the best interests of service users, the management need to take action to meet the outstanding requirements made during the last inspection and those identified as part of this inspection EVIDENCE: Ashcroft DS0000013557.V302730.R01.S.doc Version 5.2 Page 23 The responsible individual is a qualified nurse and the registered manager has experience o working with people with learning disabilities. A previous requirement was made that registered manager should compete National Vocational Qualification (level 4). The responsible individual stated that arrangements are being made for the manager to recommence the course in September 2006. A further requirement was made that matter is actioned and that the start date for commencement of this training is to be provided to the Commission for Social Care Inspection. This is to ensure that there is qualified manager who has the appropriate knowledge and skills who is able to support the service users living in the home. The home has implemented quality assurance questionnaires and the home is planning to complete an annual update. A previous requirement was made that policies and procedures need to be updated. This matter has not been achieved and a further requirement was made. Two service users are independent in handling their own monies. The responsible individual is appointee for one person. Records were sampled at the previous inspection 27th April 2006 and were adequately maintained. There was evidence that staff have received appraisals, however formal supervision needs to be updated and increased. A requirement was made that all staff should receive formal supervision at least six tines a year. A number of health and safety matters identified at the previous inspection have been resolved. Fire exits were found clear, regular water checks are recorded. Temperature records for fridge and freezer temperatures were documented. However one requirement remains outstanding that the home acquires a certificate for legionella testing. In view of the number of outstanding requirements needing action from the previous inspection this outcome area has been assessed as poor. Ashcroft DS0000013557.V302730.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 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X 2 3 X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 3 X 2 X 2 Ashcroft DS0000013557.V302730.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP7 OP9 Regulation 15(2)(a) 13(2) Requirement The registered persons must ensure that service users sign to agree their care plan. All medication administered to service users must be signed by the trained member of staff. (Previous requirement 27/4/06 not met) The complaints procedure displayed in service users bedrooms must be updated. The registered person must attend the local authority multi agency safeguarding adult training (Previous requirement 27/06/06 not met) The registered person must ensure that fifty percent of staff have gained National Vocational Qualifications (Level 2) The registered persons must ensure that all staff complete training in safeguarding adult and moving and handling training The registered persons must obtain two written references before any new member of staff commences employment in the
DS0000013557.V302730.R01.S.doc Timescale for action 03/08/06 03/07/06 3 4 OP16 OP18 4 (1)(c) 13(6) 03/08/06 03/09/06 5 OP28 18(1) 03/12/07 6 OP30 18(1) 03/10/06 7 OP29 19(4)(b) Schedule 2 03/07/06 Ashcroft Version 5.2 Page 26 8 OP22 23(2)(n) 9 OP31 10(3) 10 OP33 17(3)(a) 22(7) Shedule4 18(2) 11 OP36 home. Call bells must be installed in service users bedrooms (Previous requirement 15/06/06) not met The registered person must confirm to the Commission for Social Care Inspection the date that she is due to recommence the registered managers award The homes policies and procedures must be reviewed and updated (previous requirement 27/05/06 not met The registered manager must ensure that staff receive formal supervision at least six times a year. 03/09/06 03/08/06 03/09/06 03/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP8 Good Practice Recommendations The registered person should incorporate the health screen records of individuals as part of the individual care plan Ashcroft DS0000013557.V302730.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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