Inspection on 17/11/09 for Ashcroft House

This inspection was carried out on 17th November 2009.

CQC found this care home to be providing an Poor service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ashcroft House 01/02/10

Ashcroft House 23/06/09

Ashcroft House 25/06/08

Ashcroft House 27/06/07

Ashcroft House 12/06/06

Ashcroft House 23/01/06

Ashcroft House 11/10/05

Ashcroft House 02/08/04

Ashcroft House 14/04/04

Ashcroft House 11/02/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE Ashcroft House Fairview Close Wilderness Hill Cliftonville CT9 2QE Lead Inspector Anne Butts Key Unannounced Inspection 17 and 18th November 2009 10:30 th DS0000040622.V378561.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Ashcroft House DS0000040622.V378561.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Ashcroft House DS0000040622.V378561.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashcroft House Address Fairview Close Wilderness Hill Cliftonville CT9 2QE 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) 01843 296626 01843 571551 Manager.ashcroft@regalcarehomes.com www.regalcarehomes.com Regal Care Homes (Margate) Ltd Vacant Care Home 88 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Ashcroft House DS0000040622.V378561.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home with nursing - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) Old age, not falling within any other category (OP) The maximum number of service users to be accommodated is 88. 2. Date of last inspection 23rd June 2009 Brief Description of the Service: Ashcroft House is an exceptionally large detached property, that was previously a hospital, with three floors, which have additional wings, currently the top floor is closed whilst the company considers refurbishment requirements. The Home offers a mixture of care provisions; residential, nursing and dementia. The home is situated within walking distance of local amenities. There is a shaft lift to access the upper levels. The home has it’s own secure garden area. There is limited parking for cars available. There are additional costs for items such as hairdressing, chiropody, newspapers and taxis. Fees at this home range from £312.81 - £660 per week. Ashcroft House DS0000040622.V378561.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 stars. This means the people who use this service experience poor quality outcomes. This was an unannounced inspection which was carried out over the course of two days on 17th and 18th November 2009. Two inspectors spent one day at the home and one inspector returned for the second day. Time was spent talking to some staff and residents and observing care practices. We looked around the home and reviewed a selection of records including a selection of assessments, care plans, daily records, medication records, staff files and other relevant documents. We spoke to the manager who has been appointed by the registered provider to run the home on a day to day basis in the position of manager. They are not registered with the Commission, but will be referred to as ‘the manager’ within this report. Also present for some parts of the inspection was the operations director and a supporting area manager. They also contributed to the inspection process. An Annual Quality Assurance Assessment had been completed earlier this year and had been used to inform the last inspection. Some information from this has also been used for this inspection. The AQAA is a self-assessment, required by law. Following our last visit we also requested an improvement plan and information from this was also part of the inspection process. Judgements have been made with regards to each outcome area in this report, based on records viewed, observations and verbal responses given by those people who were spoken with. These judgements have been made using the Key Lines of Regulatory Assessment (KLORA), which are guidelines that enable the Care Quality Commission (CQC) to be able to make an informed decision about each outcome area. The focus of the inspection was to look at the progress made following the last inspection in June 2009. At that time we (the Commission) identified significant shortfalls and seventeen requirements were made. This inspection evidenced that fifteen of these requirements have not been met and further shortfalls have been identified. We are now taking further enforcement pathways in relation to the outstanding requirements. We have referred to these within the text of this report. There have been five additional requirements made as a result of this inspection. The registered provider is Regal Care Homes and they are represented by a responsible individual (who is a person nominated by an organisation to take responsibility for supervising the management of a care home). Since our visit in June the responsible individual at that time has left the organisation and a new responsible individual has registered with us. Ashcroft House DS0000040622.V378561.R01.S.doc Version 5.2 Page 6 The person who was responsible for managing Ashcroft House in June 2009 has also left the organisation and the new manager was appointed on 1 October 2009. Currently the home is subject to a safeguarding investigation by the local authority. What the service does well: The manager has recognised that there are significant shortfalls in the quality of care being provided to the people living in the home, there are however no substantive systems in place to support how the service will improve. What has improved since the last inspection? What they could do better: The Statement of Purpose and Service Users Guide have been reviewed since our last visit. The information contained in these documents is contradictory and misleading. They do not give people an accurate representation of the service and do not support people in being able to make an informed decision as to whether the home will be able to meet their needs. A poor assessment process does not evidence the home can meet individual needs and a lack of ongoing assessment means that any changing needs can not be met and responded to. Care planning and the risk management culture with the home remain poor and this means that people are placed at risk. Nutritional and fluid monitoring and support does not evidence that people’s needs are being met. Basic healthcare needs are not always met, and there was a lack of evidence to show that when someone needed more support, that substantive action was always taken. People living in the dementia care unit still do not benefit from being supported with their meals in a manner that respects them. Activities are only beneficial to some people in the home; those people who remain in their rooms or do not want to participate in organised group activities are socially isolated. Ashcroft House DS0000040622.V378561.R01.S.doc Version 5.2 Page 7 Verbal concerns raised by service users or their relatives are not recorded, which does not evidence that the service always acts appropriately in response to these. Some people living in the dementia care unit continue to have their liberty restricted as they do not have free access to and from their individual bedrooms into the communal areas and are dependent upon the availability of staff. Some parts of the building are showing signs of wear and tear and do not provide a dignified environment for people to live there. We recommend that an audit of the environment is undertaken and a plan of action developed to address these areas. Recruitment procedures are poor. Although the new manager was able to demonstrate a good understanding of recruitment procedures as required by regulation, evidence at our visit showed that Head office, however, had been responsible for the latest recruitment of new staff and they had not carried out appropriate checks in line with regulation. The registered provider is not able to recognise their responsibilities in relation to this. Despite assurance from an area manager that staffing levels remained the same – rotas viewed did not evidence this. People with nursing needs are at high risk as there is no clinical lead within the home, and the registered provider is not supporting the manager with addressing this in a timely manner. A requirement made at our last visit in relation to training still remains outstanding. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Ashcroft House DS0000040622.V378561.R01.S.doc Version 5.3 Page 8 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 House DS0000040622.V378561.R01.S.doc Version 5.3 Page 9 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Statement of Purpose and Service Users Guide do not give clear relevant information about the home so people are unable to make an informed decision about as to whether the home will meet their needs and expectations. People are not properly assessed prior to moving into the home and therefore cannot be confident that their needs will be met. EVIDENCE: Each service is required by the Care Homes Regulations (2001) to have a Statement of Purpose and Service Users Guide in place and available for current and prospective service users and their representatives. The Statement of Purpose is a legal document and as such must contain accurate and factual information so that people can be confident that the home they choose will meet their needs. Ashcroft House DS0000040622.V378561.R01.S.doc Version 5.3 Page 10 We saw that Ashcroft House has these documents in place and they are available in different formats including pictorial and large print editions. These documents have been updated since our last visit in June 2009 and changes have been made. There is no date of review on the documents and some of the information required by regulation is now not clear and other parts of the documents give information which is contradictory, inaccurate and misleading. Examples of these have been used throughout this report. Ashcroft House is registered for up to eighty-eight people and can cater for people who need residential, nursing and dementia care. There is no clear description in the Statement of Purpose or Service Users Guide to say what the assessment and admissions procedure is or how people will be supported with this. In the range of needs catered for section of the Statement of Purpose it states “We are unable to admit service users who are assessed as requiring nursing care prior to their admission to the home”. However, in another section it says that it specialises in care of the elderly with nursing needs. This information is contradictory and not in keeping with their registration. The home is registered with the Commission as a care home with nursing. At our last visit we saw evidence to show that the assessment procedure was poor and did not fully assess the needs of someone prior to them moving into the home. The manager told us that there had been no new admissions into the home since June 2009. We looked again at the admissions assessment for one person, who we had identified at our last visit as not having a full assessment. The records for this person had not been reviewed and the original poorly completed assessment was still in place. At that time we discussed this with the senior nurse on duty and the person who was managing the service at that visit and made a requirement that people are fully assessed so that the home can be confident they can meet their needs. We also looked at an assessment for a person who had moved into the home just prior to our last inspection. The pre-assessment documentation in this file was all blank and had not been filled in. There was no evidence in the file to show that this person had benefited from an assessment of need. This requirement remains outstanding and is subject to enforcement pathways. We were told that one person who had moved into the home in the earlier part of 2009 had been given notice, as the home were unable to meet their needs. This person’s original assessment was in the form of a tick list and did not fully explore individual needs. Alongside this, there was no evidence to show that the person’s needs had been reviewed on a regular basis and this meant that any changing needs were not kept under review. This home does not offer the facility of intermediate care. Intermediate care is a specialised service with dedicated accommodation, facilities, equipment and staff, aimed at maximising peoples independence to allow them to return to their own homes. It does, however, offer respite care for people on a short term basis. Ashcroft House DS0000040622.V378561.R01.S.doc Version 5.3 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People do not benefit from care plans that meet their needs and can not be confident that their health care needs, including their changing needs, will be fully met. Their safety is compromised by a poor risk management culture. EVIDENCE: Each person that lives in the home should have an individual plan of care which clearly sets out their health, personal and social care needs, together with staff support required to meet these needs. We looked at care plans at this visit in order to assess what action had been taken to ensure people were supported with an individual care plan. We asked the manager and area manager what action had been taken to review the care plans. The area manager said that currently there were different care plans in place and that they were still currently under review. We were told that the home was being supported by a healthcare professional with re-writing the care plans and that the plan was for all care plans to be Ashcroft House DS0000040622.V378561.R01.S.doc Version 5.3 Page 12 individualised and person centred. This requirement remains outstanding and is subject to enforcement pathways. A total of nine care plans were sampled, some in more detail than others. The level of information, content and layout of these plans varied significantly. One care plan we looked at contained more detail and identified individual need. However the information in this was contradictory which meant it did not give a clear picture on how the person needed assistance with their daily living. For example one part of the care plan relating to the individuals mobility said that the person was non-weight bearing and immobile, but another part of the same care plan said that the person had limited control over arms and legs. Another care plan we looked at only identified how to assist the person with their meals. The remainder of the care plan was blank; we asked about the rest of the care plan and were told that this care plan was currently being re-written but this meant that staff had no access to any other information on how to support this person. Other care plans we looked at only gave overall statements about the care and support to be given. For example a care plan stated this person was ‘reasonably mobile’, but there was no further explanation given on how to help this person. There was only limited evidence to show that individual people had participated in their care plan and overall preferences and choices were not recorded. We saw that where there was clear guidance in care plans, this was not being followed by staff. For example one care plan clearly stated that the person needed to be in an upright position when they ate their meal, however we observed this person being fed whilst they were lying down in bed. In June 2009 we made a requirement that care plans were individualised and gave clear guidance to staff with a compliance date of 30 September 2009. An improvement plan received from the registered provider stated that care plans would be reviewed and become person centric by this date. Our evidence at this visit showed that this had not happened and this requirement remains outstanding and is subject to enforcement pathways. There was a poor risk management culture in the home. There were statements relating to risk; for example ‘is at risk of falls’ but there was no supporting guidance on how to reduce this risk. Risk assessments relating to nutrition would identify that there was a risk, but again were not supported on how to manager or reduce this. At our last visit we had concerns about the movement and handling risk assessments as they did not support how staff should assist individuals and we made a requirement relating to this. We saw at this visit that the risk assessments for moving and handling people had deteriorated in quality. For example where the assessment asked about transfers it stated ‘needs assistance’. There was no guidance on how to assist. We made a requirement that risk assessments should identify individual needs and give clear guidance to staff and the improvement plan stated that this was completed by 15 September 2009. Evidence at this visit did not support this statement this requirement remains outstanding and is subject to enforcement pathways. Ashcroft House DS0000040622.V378561.R01.S.doc Version 5.3 Page 13 We also made a separate requirement to ensure that there was a safe system for the movement and handling of people including risk assessment for service users and training for staff. We required a compliance date by the 31 August 2009 and the registered provider’s improvement plan stated that this had been completed. Evidence at this visit did not support this statement this requirement remains outstanding and is subject to enforcement pathways. There are no full mental capacity assessments in individual files. For example one file stated that the person lacked capacity but there was no assessment in place. We asked the manager if there was anyone who had benefited from a full mental capacity assessment and we were told no. We did see that there was one part of a care plan in place for a person that was clear about how to support when this person became distressed. It gave clear and in depth guidance on how to manage the individual if they exhibited any challenging behaviour. However this was an isolated occurrence and not apparent in other care plans. At our last visit we had concerns about how people were monitored and supported with nutritional and fluid needs. At this visit we saw that this process had not improved and had deteriorated. The recording system allows staff to identify what and how much a person has eaten or drank, but records completed did not reflect this. For example the fluid chart for one person only showed that they had consumed 150 mls of fluid throughout the day. A food chart for a person only showed that they had eaten some jelly and toast over a period of three days. Records for one person were contradictory about the consistency of their meals. For example one part of the care plan said food should be liquidised, another part said pureed and when we spoke to staff they said it should be of a soft consistency. This did not evidence that there was a consistent approach that met individual need. Nutritional assessments would identify that the person was at risk of malnutrition, but there was no information on how to support the person or reduce this risk. The home’s improvement plan said that accurate nutritional records would be maintained and that this was completed by 31 August 2009. Records we viewed evidenced that this had not happened and this requirement remains outstanding and is subject to enforcement pathways. The monitoring of some people’s weight had improved since our last visit in that people were weighed on a more regular basis. However staff were not following guidance in care plans; for example one care plan stated that the person should be weighed on a weekly basis but this had not happened. There was still no evidence to show that any appropriate action was taken if there was any significant weight loss. The area manager told us that a new procedure had been instigated in relation to weight loss, but this had not yet be given to staff or embedded into the working culture of the home. this requirement remains outstanding and is subject to enforcement pathways. At our last visit we also had concerns about how people are monitored in relation to any bruising and what action was taken relating to this. At this visit we saw that staff are recording if there is a bruise or mark, but are taking no further action. The improvement plan stated that these would be clearly recorded and any triggers would be acted upon. Records did not show that there was any exploration as to how a person bruised themselves and there was no risk reduction management in place. Ashcroft House DS0000040622.V378561.R01.S.doc Version 5.3 Page 14 Daily records and monitoring sheets are not showing that people are receiving full personal care. For example records for one person showed that they had only received person care support on six days out of seventeen. One person told us that they are not supported to have a wash or have their teeth cleaned before they go to bed. At our last visit we made a requirement that records are maintained to show that people’s needs are being met and the registered providers improvement plan identified that this was in place. Evidence seen at this visit did not support this and this requirement remains outstanding and is subject to enforcement pathways. There are systems in place for half hourly checks on people who stay in their rooms or in bed, but records did not show that this was happening. For example records showed that one person had only been checked once on one day and four times on another two. Staff said that they did not always have time to do this. People are not always supported with maintaining their privacy and dignity. For example doors to bedrooms were left open when people were being assisted with personal care or not dressed. We observed one person walking around the home with a wet pad half way down their trousers before staff identified this person needed assistance. At our last visit we required that the home ensured that people were supported in a manner that respects their privacy and dignity and the improvement plan stated that ‘current measures would be assessed and new measures implemented’. This had not happened and this requirement remains outstanding and is subject to enforcement pathways. Records are put into place for people who have a pressure area, but records did not show that people were assisted to move position to alleviate the area. For example one person who had a pressure sore on their sacrum had only been turned twice in a twelve hour period. A pressure area assessment is being completed in the dementia care unit by untrained staff, so putting people at risk. Processes for providing people with the appropriate equipment to meet their needs continue to be slow. We identified in June that one person needed a specialised sling. The manager now in place had arranged for this to happen and the sling was delivered on 18 November, however this should have been in place prior to this. Medication processes were examined on the dementia care unit. There is a dedicated medication room and the storage facilities are adequate for the needs of the unit. There is suitable storage space and controlled drug facilities. The medication was seen to be stored in an orderly manner and stocks viewed were in date. Records were maintained for all controlled drugs and each entry was double signed. A stock check of this medication is carried out on a weekly basis. Staff have been trained in medication but as identified at our last visit this is through the use of a DVD training system and does not assess staff on their competency to administer medication. Medication protocols for assisting people with ‘as and when’ medication is not in place and this needs to be addressed. We have also been informed through sharing information protocols that there are concerns about the management of medication in the home and a visit carried out by another statutory body on a different day found shortfalls. They have given the home their own action plan for medication and we are supporting their findings. Ashcroft House DS0000040622.V378561.R01.S.doc Version 5.3 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are a range of social activities which do provide stimulation and interest to some of the people living in the home. Not all people benefit from this or have the opportunity to participate in activities which meets individual needs. People do not always find that the lifestyle experienced in the Home matches their expectations and supports their preferences and choices. There is a varied menu with a choice of meals, not all people are supported with their meals in a manner that respects and promotes their dignity. EVIDENCE: There is a leisure therapist employed for each floor and their role is to arrange activities and support people with their social needs. On the first day of our visit an entertainer had been arranged to put on a show on the ground floor. Many people from the dementia unit also attended this. People we spoke to Ashcroft House DS0000040622.V378561.R01.S.doc Version 5.3 Page 16 after the entertainment had finished were all complimentary and said that they enjoyed the singing. On the ground floor the leisure therapist works for five hours a day for five days a week. Records showed that there is a range of activities available including bingo, exercises, quizzes and reminiscence. People who were in the lounge area on the days of our visit all said that they enjoyed different aspects of the activities available. The leisure therapist in the dementia care unit works from 10.00am – 6.00pm for five days a week. She continues to promote doll therapy and we observed that time was spent with people doing puzzles, colouring and arts and craft sessions. We observed, however, that activities tended to be reserved for the communal areas and there was limited time to spend with people who for reasons of ill health or possibly choice spend more time in their own bedrooms. There was very little information in the care plans on both floors relating to peoples preferences and preferred pastimes. For example one persons care plan for their social needs stated ‘when family visit offer refreshments’ and for another person this part of the care plan only stated ‘prefers not to participate’. We saw this service user on the dementia unit and they asked us on several occasions if we could show them the way out as they wanted to go out for a walk. We asked care staff if this person had the opportunity to go out, and we were told ‘no – they may have gone out into the garden a couple of times in the summer but it is not happening now’. This person also asked us if we were going anywhere near the football ground of their favourite team. Care staff told us that this person was an avid football supporter; but the care plan did not state this or identify any activities that they could become involved which were football related. We observed that people who spent time in their rooms were isolated with little interaction from staff apart from occasional safety checks. Two people told us they got bored in their rooms with one person saying ‘I am bored to tears’. Another person said ‘I prefer to stay in my room but no one comes to see me it is very disappointing’. People on the dementia unit who tended to wander were able to, but this was an isolated activity for them with no support or positive interaction from staff. The Statement of Purpose declares that one of the objectives of the home is ‘To provide stimulation and encouragement to maintain as many previous skills, interests, activities and friendships as possible in or out of the home and the opportunity to develop new interests and friendships’. There is no evidence to show that people are given the opportunity for this and the routines of the home do not promote this. Families are encouraged to visit and maintain contact with their relatives. A requirement was made at our last visit that people are supported in making decisions in relation to their care needs and that care plans identify individual choices particularly in relation to bathing, food and care. We spoke to two service users who both said that they had to get up when staff are ready and tell them to. Another person told us that they can only have a bath when staff are available. We asked one person if they chose to stay in their room and they told us ‘there is nowhere else to go’. Care plans lacked any Ashcroft House DS0000040622.V378561.R01.S.doc Version 5.3 Page 17 meaningful information relating to choice, some did identify a preferred time of getting up or going to bed but other preferences were not recorded. For example a care plan said that the person ‘did not appear to have any dislikes for meals’. This is an assumption and had not been explored either with the service user or their relatives. At our last visit in June 2009 we observed that the mealtimes in the dementia care unit were institutionalised with people routinely being given protective aprons to wear regardless of need and lack of choice of drinks and meals. There were some improvements in this area at this visit. There was a choice of drinks available and people ate different meals. It was encouraging to see that the menu is now available in a pictorial format, so supporting people with making a positive choice. Meals were seen to be nicely presented and people we spoke to were mainly positive about the food. One person said that they felt that the evening meal was not enough for a grown man and we discussed this with the manager at the time of our visit. We observed, however, that the mealtime on the dementia unit still more of a routine chore than a positive social activity for people. For example people were still routinely given protective aprons, and observations showed that only two people needed them. People remained seated in wheelchairs and these were positioned in such a manner that it meant some people were sitting too far back from the table which resulted in them dropping food onto their laps. There were no adapted cutlery or plate guards and one service user was seen to be trying to drag food onto conventional cutlery and this resulted in the spilling of food. The mealtime was very quiet with no interaction between service users and only limited interaction from staff. People who stay in bed have their meals served to them in their rooms. We saw that one person had the meal placed on a lap table at the side of the bed. This meant that this person then had to eat their meal in a sideways twisted position half lying down and half leaning on their elbow which made it very awkward for the person to manage their meal. The care plan for this person said that they did not like to sit in a chair or at the edge of the bed, but did not identify how this could be managed. The registered provider’s improvement plan said that they would reassess people’s needs in relation to their food, bathing and care and that this was completed by 30 September 2009 and would be kept under ongoing review. Evidence at this visit did not support that people in the dementia care unit had benefited from a reassessment in relation to their meal times. Conversations with people living in the home did not support that they were supported with their preferred choices. The improvement plan also said that care plans would document individual needs. In the care plans we looked at we did not see substantial evidence of this with examples of shortfalls given throughout this report. A requirement made relating to individual choices and decision making remains outstanding and is subject to enforcement pathways. Ashcroft House DS0000040622.V378561.R01.S.doc Version 5.3 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints and concerns are acted upon, but lack of robust recording does not support this process. Not all people living in the home are safeguarded by the management of their care and support needs. Individual mental capacity is not taken into consideration. EVIDENCE: The Statement of Purpose contains the complaints procedure and clearly states that all complaints and concerns will be resolved within twenty-eight days and that those both in writing and verbally will be treated on an equal basis. We asked the manager if there had been any complaints and we were told no. She did say that someone had voiced a concern but had not made an actual complaint. The manager told us that she had dealt with this and it had now been resolved. We asked if this had been recorded and we were told no. If a complaint or concern, either verbal or written are to be treated on an equal basis – then full written records need to be maintained to demonstrate this. A person living in the home told us that they had been requesting internet access in their room for over three months. They told us that they had recently spoken to the new manager and that it was now being addressed. We spoke to the manager about this and she confirmed that they were looking into this. It is not good practice however, that this person had to wait three months before any action was taken to what can be considered a reasonable request. Ashcroft House DS0000040622.V378561.R01.S.doc Version 5.3 Page 19 We spoke to other service users who said that the manager was available to talk to if they had any concerns. At our last visit we identified that there had only been limited training in the Mental Capacity Act and none in relation to Deprivation of Liberty Safeguards. We asked the manager about training in this area and she told us that there had not been any additional training since our last visit. She said that a training day had been booked for The Mental Capacity Act for herself and a senior for the week following our visit. We saw proof of this. She told us that there were currently no plans for Deprivation of Liberty training but she was discussing the subject of Deprivation of Liberty with staff during supervision and giving them government guidance leaflets. We saw evidence of this in staff files. It is accepted that staff are being made aware of these issues, but appropriate training needs to be given in this area. As identified at our last visit we were concerned about the restriction of liberty for people living in the dementia care unit as there are two areas within this unit that can only be accessed by a keypad. One area is currently unoccupied but many of the bedrooms in the other area are in use. We made a requirement that unnecessary restrictions were not placed on people’s liberty. At this visit we asked what had been done to address this. Neither the area manager nor the manager who had since taken up position with organisation was able to give us a clear answer. The improvement plan presented by the registered provider following our last visit stated that a bell had been installed. We spoke to a senior on the dementia care unit and we were told that ‘there are a couple of people who are able to let themselves in and out’. However there are still people whose bedrooms are behind these doors and they do not have unrestricted access in and out of this area. At our visit on 17 November 09, we went to this part of the dementia care unit with the representing area manager to explain what our concerns were. On opening the main door we heard loud banging and crying coming from a vacant room. We found that a service user had barricaded themselves in this room by pushing a lap table against the door. This person was frightened, hallucinating and did not want to come out of the room. After a few minutes of gentle persuasion the area manager was able to open the door slightly – the room was in darkness and the service user could be heard to be crying. They told us there were scared and that they did not want to come out. The service user was supported to come out of the room and taken back to their own bedroom. Records showed that this person had last been checked on half an hour previously and it is not known how long they were in this state of distress since this time. The banging could not be heard outside of this locked area and we were told this person was not able to let themselves out into the main corridor, this meant that they were isolated and vulnerable. At the second part of our visit on 18 November 2009, we looked at the records for this person. We saw that the records identified that they could become distressed and suffer hallucinations and that this was a high risk. However, this person has been allocated a room behind closed doors, where there is no permanent staff presence and with no strategies in place on how to safeguard them. The care plan also stated that this person had a tendency to wander but did not identify as to how they could let themselves in or out of the locked corridor. Staff told us that originally this person had been allocated a room in the main part of the unit, where there is more staff presence but gave us two different Ashcroft House DS0000040622.V378561.R01.S.doc Version 5.3 Page 20 explanations as to why they had been moved to an area behind locked doors – so evidencing that staff were not clear as to the reason and that this had not been fully reviewed so check as to the safety of this person. The daily records for the person did not record the incident and therefore this has the potential to place them at risk as many staff may not be fully aware of their individual needs. This requirement remains outstanding and is subject to enforcement pathways. Staff have not received updated training in safeguarding vulnerable adult procedures despite the fact that at our last visit we found that the training had been delivered by an unqualified trainer through the use of a DVD. We spoke to staff about safeguarding adults and they were clear that they would report concerns to either the manager or a statutory body. There is currently an ongoing safeguarding investigation open on Ashcroft House and this is being looked at through the Kent and Medway adult protection protocols. We (the Commission) have not received any complaints about the service since our last visit, however through information sharing protocols we are aware of the safeguarding concerns relating to this home. Ashcroft House DS0000040622.V378561.R01.S.doc Version 5.3 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home do not benefit from an environment which is safe and well maintained. The home is generally clean and some people benefit from having personalised their bedrooms. EVIDENCE: Ashcroft House was formally a hospital and is located in the centre of Cliftonville close to the coastal town of Margate. It is a large building built in the 1930’s and sits in its own grounds. It is situated close to local shops and bus routes. Ashcroft House DS0000040622.V378561.R01.S.doc Version 5.3 Page 22 The home is currently laid out over two floors with the ground floor accommodating people with residential and nursing needs and the first floor accommodating those people with a diagnosis of dementia. There is a second floor which is currently not in use. On arrival at Ashcroft, the building does not give an overall good impression as paint was peeling and windows were dirty. Internally areas of the home did not always present a dignified place to live. For example in the dementia care unit many of the bedroom carpets were dirty, sticky underfoot and in places threadbare. In one bedroom the curtains were hanging down from the window and there was a second unoccupied bed which was unmade with a blue plastic mattress on show. We asked a member of staff about the curtains and we were told ‘that they had been like this for over a week’. Many of the light fittings did not have lampshades and suitcases and baggage was stored on top of wardrobes. Some bedrooms on this floor were also seen to be impersonalised and with little evidence of the identity of the person and few personal belongings. In the bedrooms on the ground floor, which is the nursing and residential unit, we saw that there was more evidence of rooms being personalised with peoples own possessions including photographs. There was no door leading to the bathroom and sluice area on the dementia unit and doors to the bathroom and sluice room were open. There were no thermostatic valve controls on the taps in the bathrooms and we observed service users wandering in and out of this area. Open sluice rooms and unregulated water temperatures have the potential to put service users at risk. A sluice room is a high infection risk area and there were missing tiles on the walls which meant that this area could not be cleaned properly. Also in the dementia unit there was a recess with no doors which contained an electrical box which had the sign ‘Danger of death’ on it. We pointed this out and during our visit the maintenance men started to construct a doorframe and fit doors to this. The home was mainly odour free, although the reception area in the dementia unit and the downstairs lounge both exhibited strong odours. Some areas of the home have worn or damaged surfaces including doors in dementia unit which have holes in and are splintered, a window had black masking tape around it and another window did not close properly leaving gaps around the seal. There is a lift to the first floor and on each floor there are sets of steps leading to the right and left wings of the building. This means people with mobility difficulties are dependent upon staff and the lifts being serviceable at all times. We spoke to two people who said that the stair lift to their bedroom area had on more than one occasion broken down. They said that this meant that they had to stay in their room when this happened and this caused inconvenience. On the dementia care unit there are also key padded doors to these areas. This is discussed in more detail below and in the complaints and concerns section of this report. There are still two areas on the dementia that can only be accessed via a keypad system and if a person’s bedroom is in this area they either need to know the number or have a member of staff available to open the door for them. At our last visit we identified that this had the potential to restrict people’s liberty within the environment they call their home and Ashcroft House DS0000040622.V378561.R01.S.doc Version 5.3 Page 23 we asked that this be reviewed. We saw at this visit that this had not been appropriately reviewed and still resulted in some people not having unrestricted access to their own bedrooms. This requirement remains outstanding and is subject to enforcement pathways. A new call bell system has now been fitted and is available in the main communal lounge areas. Some of the bedrooms are shared occupancy including bedrooms on the dementia care unit. Although the home is not currently full people are still sharing a room and there was no evidence to show that they everyone sharing rooms had made an informed decision to do so. Also as rooms have become vacant this has meant that some people’s bedrooms are at the end of long corridors and they are isolated from the rest of the home. The Health and Safety Executive has also carried out an inspection at the home and has made requirements with regards to action they need to take. We are supporting this by making a requirement that the registered provider ensures that they meet with any requirements made by this statutory body. Ashcroft House DS0000040622.V378561.R01.S.doc Version 5.3 Page 24 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The registered provider has failed to protect people living in the home through robust recruitment procedures. People benefit from being supported by staff that are kind and caring but continued lack of appropriate training means they cannot be confident that staff are competent. EVIDENCE: We looked at recruitment procedures for the home and viewed the files for two new members of care staff. We saw that these two members of staff had been employed through an employment agency and that their recruitment had been carried out by a member of the senior management team. The records showed, however, that these checks were not robust and are not in line with the Care Homes Regulations 2001 and associated schedules. References on file were only addressed to ‘To whom it may concern’ and there was no evidence to show that their validity had been authenticated. These members of staff are working in the UK through a study programme at a London College and we saw a visa on file, but again there was no evidence to show that the organisation had completed checks on these. We asked the manager if there was anything in place to confirm that these documents were authentic and she told us that the home had received verbal confirmation from head office, but nothing else. This is not acceptable and it is the registered provider’s responsibility to ensure that there are robust recruitment procedures in place. Further concerns with regards to the registered providers Ashcroft House DS0000040622.V378561.R01.S.doc Version 5.3 Page 25 understanding of recruitment procedures have been identified in the Management and Administration section of this report. We did see that members of staff are in receipt of Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) check prior to starting work in the home. We spoke to the manager about recruitment procedures and she was able to demonstrate a clear understanding of the requirements of legislation, unfortunately she is not supported by the organisational activity despite the declaration in the Statement of Purpose which says ‘The home’s staff are selected for their qualities ……They are carefully screened and references are always checked thoroughly’. We looked at the file for a newly employed auxiliary member of staff and saw that there was only one reference in place and the home was still waiting for the CRB to be returned, although there was a POVA check in place. It is accepted that the member of staff does not work on a one-to-one basis with people but is still working within the home without full references being obtained. The Care Home Regulations require all staff to undertake induction training. The Statement of Purpose for Ashcroft House says that all staff will complete an induction that follows the Skills for Care guidelines. Records for the two new members of staff did not show any evidence that they had undertaken any induction, although rotas showed that they had worked three days on shift and were allocated as extra members of staff. They are, however, now working night duty with no evidence of a Skills for Care induction in place. At our last visit in June 2009, we identified that training was a high concern and there were significant weaknesses in the training programmes as many staff had been given training through the use of DVD’s and did not undertake any practical sessions or competency assessments. We asked the manager what had been done to address the training concerns. She told us that there had been some training and this included fifteen staff attending training in health and safety and infection control. There had been training arranged for managing challenging behaviour and dementia care, but both of these had to be cancelled as there would not be enough staff available to work in the home. We asked about movement and handling training and were told that this had not been updated since our last visit. At that time we had high concerns with regards to this training in particular as it again consisted of watching a DVD and contained no practical which does not meet with meet with health and safety legislation. Staff had also been trained by the previous manager who was not qualified to deliver this training. The manager told us that hoist training had been arranged for staff, however untrained staff have continued to support people with their movement and handling needs since June 2009, therefore increasing the potential to place people living in the home at risk. The files for the two new members of care staff did not evidence that they had undertaken any of the required mandatory training, despite being allocated on nights. On the first day of our visit, nine members of staff had attended a training course on nutrition. One member of staff spoke to us about this and said that it had been ‘very good and beneficial’. We asked for a training matrix but were not given one, therefore our conclusions are based on conversations with the manager and staff and records viewed in files. It is accepted that some areas of training have been addressed, but the majority of staff have Ashcroft House DS0000040622.V378561.R01.S.doc Version 5.3 Page 26 still only received basic awareness training through the use of DVD’s in many areas of mandatory training. It is the registered provider’s responsibility to ensure that staff are trained in the specialist needs of the people living in the home, including induction training. This requirement, therefore, remains outstanding and is subject to enforcement pathways. We looked at rotas for a four week period over the course of October and November 2009. We asked if these were an accurate representation of the actual hours worked and we were told that they were. The area manager told us that even though there was a reduced occupancy level in the home, staffing levels remained the same. The rotas showed that for the ground floor there are five care staff allocated for the morning and four care staff for the afternoon shift, plus a registered nurse for each shift during the period we looked at. This was different to our findings in June when six care staff, plus a registered nurse were allocated on shift in the mornings on the ground floor. The rotas for the ground floor did not always show that there was a registered nurse allocated on duty. For example for the week beginning 2 November 2009 there were two full days plus a morning and two afternoon shifts without a named nurse on the rota. Since our visit we have been made aware, through sharing information protocols under safeguarding, that there was one occasion where the nurse on duty was not available on the floor for a period of four hours so leaving people living in the home at risk. Rotas for the dementia care unit showed that there are five care staff on duty for the morning shift and four care staff on duty in the afternoon. This includes the senior on duty who is responsible for leading the individual shifts. Rotas for night duty also did not always indicate that there was a named nurse or agency nurse identified. They also showed that sometimes there were three carers on duty at night and at other times four carers. There are ancillary staff allocated for laundry, cleaning and kitchen duties. People we spoke to whose rooms are on the ground floor also said that ‘staff are very busy and sometimes it takes a long time for them to respond to the call bell’ and ‘I know they are trying their best but they are very busy’. One person told us ‘there is not enough staff and sometimes I have to wait to be helped out of bed and I am not always able to have a bath when I want to’. This person also added ‘the staff do try hard’. A requirement made at our last visit regarding staffing levels remains outstanding and is subject to enforcement pathways. Ashcroft House DS0000040622.V378561.R01.S.doc Version 5.3 Page 27 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36 and 38. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager is committed to making improvements in the home, however lack of quality support from the registered provider and no clinical lead means that people are being put at risk. A lack of a timely response to addressing previous requirements does not safeguard people living in this home. People are not receiving a consistent quality service due to the lack of management structure within the home. EVIDENCE: Ashcroft House DS0000040622.V378561.R01.S.doc Version 5.3 Page 28 Since our last visit there has been a change in both the management of Ashcroft House and the responsible individual for Regal Care Homes Ltd. The new responsible individual took up post in August 2009. The previous manager left at the end of August and the new manager started in her post on 1 October 2009. A deputy manager also took up post at the end of August, but has since stepped down from this position and the home currently does not have a deputy manager. The nursing unit continues to operate without a clinical lead and the dementia care unit is still only run on a temporary basis by two senior carers with no stable management structure in place. The new manager in post is not a registered nurse, and although within regulation care homes with nursing do not have to have a registered nurse as the registered manager, it is the registered providers responsibility to ensure that there is a clinical lead to manage and support the care of service users with nursing needs. This is not in place at Ashcroft House. The manager and deputy manager were recruited by senior management representatives of Regal Care Homes. We returned to the service and met with the operations director to look at the recruitment procedures for the management of the service. We saw that these were not robust, neither the manager nor deputy manager had been requested to complete an application form, although a c.v. was in place. An application form, however, contains more information as required by regulation including a statement in relation to the rehabilitation of offenders act and a declaration of health. The organisation had also allowed the deputy manager to start work prior to receiving references and records showed that despite starting on the 31 August 2009, references were not received until November 2009. One of the references was also addressed ‘To whom it may concern’, and there was no evidence to show that this had been authenticated. Neither record showed any evidence of a structured induction programme. We spoke to the operations director and asked about the management recruitment procedure. We were told that following difficulties in appointing a manager and that once a suitable candidate had been found they were keen for the person to start. It is the registered provider’s responsibility to ensure that there are robust recruitment procedures in place. A requirement made at our last visit for staff only to be employed in line with regulation has not been met and is subject to enforcement pathways. The manager told us that she had interviewed for a ‘Head of Care’ and she was able to demonstrate that she was following recruitment procedures as required by regulation. Staff records showed that the manager had started a supervision process with care staff and was using this process to give staff information relating to policies and procedures and some good practice guidelines. Staff we spoke to said that the manager was supportive and available. At this visit we did not see any evidence of a robust quality assurance process. The deputy manager was in the process of carrying out an audit of accidents and incidents but was unclear as to what would happen to this information once it had been completed. When the registered provider is an organisation it their responsibility to ensure that the care home is visited on a regular basis by the responsible individual or a nominated person for the organisation to carry out a quality assurance visit known as a Regulation 26 visit. The last visit had been carried out in October 2009 and the report showed that the Ashcroft House DS0000040622.V378561.R01.S.doc Version 5.3 Page 29 nominated person had spoken to service users and staff. It had identified that care plans were in the process of being re-written but had failed to identify that many of the records maintained in the home were not to a standard which supported the care needs of the people living there. The manager has reintroduced some safety checks. As identified elsewhere in this report we have concerns about how people are supported with their mental capacity needs and what is in place to ensure that people are not subject to any deprivation of liberty. We asked if any one living in the home had received a full assessment relating to this. The manager told us that they had requested a mental capacity assessment for one person. This was not in place for anyone else. Ashcroft House DS0000040622.V378561.R01.S.doc Version 5.3 Page 30 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 1 X 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 1 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 2 2 2 1 1 1 2 2 STAFFING Standard No Score 27 1 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X X 2 1 1 Ashcroft House DS0000040622.V378561.R01.S.doc Version 5.3 Page 31 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4 Requirement ‘The registered person shall compile in relation to the care home a written statement The Statement of Purpose’’. In that the current statement of purpose and service users guide are reviewed and give accurate, un-contradictory and factual information about the services which are to be provided. The registered person shall ensure that people living in the home receive proper provision for the health and welfare of service users. In that full records are maintained in respect of pressure sores and the treatment provided. The registered person shall having regard to the size of the care home and the number and needs of service users – consult service users about the programme of activities arranged on or behalf of the care home, and provide facilities for recreation including, having regard to the needs of the service user, DS0000040622.V378561.R01.S.doc Timescale for action 31/01/10 2 OP8 12 (1) Schedule 3 (3)(n) 31/01/10 3 OP12 16(2)(n) 31/01/10 Ashcroft House Version 5.3 Page 32 4 OP19 13 (4) (a) 5 OP31 8 activities in relation to recreation, fitness and training. This is to ensure all service users social needs are met. The registered provider shall ensure that all parts of the home are free from hazards. This is so that people are not subject to any risks. Any person who carried on or manages an establishment or agency of any description without being registered under this part in respect of its (as an establishment or, as the case may be, agency of that description) shall be guilty of an offence. Care Standards Act 2000 (11 (1)). In that an application be made for a registered manager by date set. 31/01/10 28/02/10 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ashcroft House DS0000040622.V378561.R01.S.doc Version 5.3 Page 33 Care Quality Commission South East Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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