Inspection on 01/11/07 for Ashcroft Rest Home

This inspection was carried out on 1st November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 Rest Home 29/05/08

Ashcroft Rest Home 24/04/07

Ashcroft Rest Home 24/11/06

Ashcroft Rest Home 28/06/06

Ashcroft Rest Home 23/02/06

Ashcroft Rest Home 12/04/05

Ashcroft Rest Home 07/12/04

Ashcroft Rest Home 02/07/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Ashcroft Rest Home 27-29 Chadwick Road Leytonstone London E11 1NE Lead Inspector Rob Cole Unannounced Inspection 1st November 2007 09:30 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 Rest Home DS0000007230.V353844.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 Rest Home DS0000007230.V353844.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashcroft Rest Home Address 27-29 Chadwick Road Leytonstone London E11 1NE Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8530 6072 020 8530 6072 ashcroftres@btconnect.com Ms Hyacinth Valeska Sandilands Mrs Neva Bernice Gilpin Ms Hyacinth Valeska Sandilands Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Ashcroft Rest Home DS0000007230.V353844.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th April 2007 Brief Description of the Service: Ashcroft Rest Home is a care home providing personal care, support and accommodation to up to 15 older people. The home, which is privately owned and operated, is located in a residential area of Leytonstone in East London. There is easy access to local shops and other amenities. The property is two storey with bedrooms situated on both the ground and first floor. There are two double rooms with the remainder for single occupancy. There is a stair lift available on one set of stairs with a separate staircase for those who are more mobile. There is a rear garden available and accessible to residents with support of staff. The current range of fees charged by the home is between £420 and £500 per week. Ashcroft Rest Home DS0000007230.V353844.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on the 1/11/07 and was unannounced. The inspector had the opportunity of speaking with service users, staff from the home, and the homes manager was present for most of the inspection. The inspector was able to observe staff interaction with service users, which helped to provide evidence for this report. The inspection also included an examination of records and other documents, and a tour of the premises. Prior to the inspection the home completed an Annual Quality Assurance Assessment (AQAAQ) at the request of the CSCI. This has also contributed to the overall inspection process. What the service does well: What has improved since the last inspection? What they could do better: Despite these improvements, there remains a considerable amount of work to be done before the home is fully compliant with National Minimum Standards and the Care Homes Regulations 2001. In particular, the home must ensure that all medications are administered and recorded appropriately, and that all staff undertake training in adult protection issues. Ashcroft Rest Home DS0000007230.V353844.R01.S.doc Version 5.2 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ashcroft Rest Home DS0000007230.V353844.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashcroft Rest Home DS0000007230.V353844.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the judgement of the inspector that service users are provided with sufficient information about the home to make an informed choice as to move in or not. This information is provided through written documentation and the opportunity of visiting the home. EVIDENCE: The home has both a Statement of Purpose and Service User Guide in place. The inspector was pleased to note that both of these documents have been revised since the previous inspection, and that they are now both in line with National Minimum Standards (NMS). They are written in plain English, and all service users are provided with their own copy of the Service User Guide. Ashcroft Rest Home DS0000007230.V353844.R01.S.doc Version 5.2 Page 9 The Statement states that “Ashcroft endeavours to provide the highest possible service to all its service users. All service users have the right to maintain maximum independence. All service users will be shown respect from those involved in their care.” The Guide includes details of the physical environment and of the homes complaints procedure, while the Statement includes details of the services and facilities provided and of the registered persons. The home has an admissions procedure. This makes clear that service users will be given the opportunity of visiting the home prior to admission. There has been one new admission to the home since the previous inspection. This was an emergency admission, in line with the homes admission procedure. An assessment of their needs was carried out very shortly after they moved into the home. This covered needs around health and mobility. All service users are provided with a written contract/statement of terms and conditions. These include details of fees payable, what these fees cover, and what they do not include, along with details of the facilities and services provided. The home does not provide intermediate care. Ashcroft Rest Home DS0000007230.V353844.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that the home is generally able to meet the health and social care needs of service users. However, the home must ensure that all medications are administered appropriately, and that comprehensive care plans and risk assessments are in place for all service users. EVIDENCE: Care plans are in place for all service users. The inspector was pleased to note that since the previous inspection these are now subject to regular review. Care plans were generally of a satisfactory standard, and clear and easy to understand, covering needs around mobility, social and leisure activities and health. Service users and relatives are involved in drawing up care plans. Ashcroft Rest Home DS0000007230.V353844.R01.S.doc Version 5.2 Page 11 However, not all care plans are sufficiently comprehensive and detailed. For example, one service user has a diagnosis of dementia, yet their care plan (or their risk assessment) make no mention of dementia, how the home can meet their needs around dementia, or what risks may be involved. It is required that all care plans are comprehensive, detailing how the home can meet all the needs of service users. As with care plans, the overall standard of risk assessments has improved since the last inspection. At the last inspection it was found that risk assessments were not in place for several service users. It was noted that a risk assessment could not be found for one service user during the course of this inspection, (although the manager informed the inspector that they thought one had been completed) and therefore the requirement is repeated that comprehensive risk assessments are in place for all service users. Assessments that were in place were generally of a satisfactory standard, covering risks associated with personal hygiene and falling, and were subject to regular review. Assessments identified risks, and included strategies to manage and reduce these risks. All service users are registered with a GP. Since the last inspection the home now keeps records of medical appointments, including information of any follow up action required. There was evidence that service users have access to health care professionals as appropriate, including psychiatrists, chiropodists and since the last inspection dentists. To help service users maintain and develop their general health and fitness, it runs a weekly gentle exercise class, and various other activities to help promote fitness. The home makes use of the Continence Advisory Service, who supply advice along with continence products. Used continence products are disposed of appropriately. The home has a medication policy in place. All staff have training before administering medications. Medications are stored securely in a locked cabinet within the office, and the inspector was pleased to note that any medications stored in the fridge are now stored in a locked container. No service users are currently on any controlled drugs, and no service users self medicate. Records are maintained of medications entering the home, and of those that are returned to the pharmacist. Medication Administration Record (MAR) charts are maintained. However, these were found to contain several unexplained gaps over the past four weeks, thus making it impossible to verify if the medications had been administered appropriately on those days. It is required that all medications are administered and recorded as appropriate. The manager informed the inspector than service users would be able to remain in the home with a terminal illness, as long as the home was able to meet their medical needs. The home has sought and recorded the views of service users on the arrangements to be made in the event of their death. Ashcroft Rest Home DS0000007230.V353844.R01.S.doc Version 5.2 Page 12 Through observation and discussion there was evidence that service users privacy is respected. For instance, staff were seen to knock and wait for an answer before entering bedrooms. Service users are given their own mail to open, and have access to a telephone they can use in private. Ashcroft Rest Home DS0000007230.V353844.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that service users have control over their daily lives, and that the home provides appropriate activities. EVIDENCE: The home provides various activities. As mentioned, someone visits the home weekly to conduct a gentle exercise class. This was in progress during the course of the inspection. The inspector observed it to be well attended, and service users were seen to be actively participating in the activity, and enjoying it. London Mobility also visit the home once a month, who provide service users with various activities such as ball games designed to develop and maintain general fitness and mobility. The home also arranges various social and leisure activities, such as sing-alongs, quizzes, TV, music and BBQ’s. Members from a local church regularly visit the home thus helping to meet service users needs with regard to Ashcroft Rest Home DS0000007230.V353844.R01.S.doc Version 5.2 Page 14 equalities and diversity issues. One service user is from Jamaica, and the home provides Jamaican food, and the service user has their hair styled in a traditional Jamaican style, again, helping to meet needs around equality and diversity issues. Visitors are welcome at the home at any reasonable time, and service users can see visitors in private if they so wish. Service users are given their own mail to open, and have access to the use of a private telephone. Service users are able to go out with visitors, for example for a pub lunch or to the park. Through observation and discussion there was evidence that service users have control over their daily lives. It was clear on the day of inspection that service users have choice over when to get up, and service users informed the inspector that they are able to choose their own clothes to wear. Service users were seen to move freely around communal areas of the home. The home holds joint meetings for service users and relatives. Minutes evidenced discussions around activities and menus, along with decoration to the home. Since the previous inspection the home has had a considerable amount of decoration carried out, and there was evidence that service users were involved in choosing new décor. Service users are involved in planning the weekly menu, and a record is maintained of the menu. This evidenced that service users are provided with a balanced, varied and nutritious diet. On the day of inspection service users were offered a choice of beef casserole or meatballs. Service users were seen to enjoy the meal, one commented that “Lunch was very nice.” A choice of deserts was also offered. Support provided at mealtimes was done so in a sensitive manner, and mealtimes were observed to be relaxed and unhurried. Fresh fruit was available, and there was evidence that fresh produce is routinely used in cooking. Service users are offered drinks and snacks throughout the day. The kitchen was clean and tidy. Since the last inspection the home has obtained a set of colour coded chopping boards, and the inspector was pleased to note that all staff involved in food preparation have now undertaken training in food hygiene. However, although records of fridge and freezer temperatures are maintained, it was noted that the fridge temperature on the day of inspection was 13 degrees centigrade. The fridge door does not close automatically, and there was a sign on the door reminding staff to make sure they close the door firmly. It is required that the fridge is maintained at a temperature between 2 and 8 degrees centigrade, to ensure that food remains safe for consumption. Ashcroft Rest Home DS0000007230.V353844.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 and 18. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Although the home has appropriate polices in place around complaints, more must be done to help safeguard service users from the risk of abuse. For example, all staff must undertake adult protection training, and adult protection policies must be in line with current legislation. EVIDENCE: The home has a complaints procedure in place. A copy of this has been put on display within the home since the previous inspection. The procedure includes timescales for responding to any complaints received, and contact details of the CSCI. Service users spoken to demonstrated a good understanding of whom they could complain to if they so wished. The home also has a complaints log, although the manager informed the inspector that no complaints have been received since the previous inspection. Since the last inspection the home has obtained a copy of the Local Authorities adult protection procedures. It also has its own policy in place on adult protection. However, this contains contradictory information, some of which is not in line with current legislation. On page 1 of the document it states that Ashcroft Rest Home DS0000007230.V353844.R01.S.doc Version 5.2 Page 16 any allegations of abuse must be reported to the Local Authority (LA), who would then have responsibility for the issue, while on page 2 it states that the allegation must be reported to the CSCI, and that they would then have responsibility. In fact, both the LA and the CSCI should be informed of any allegations of abuse, but it is the LA who have responsibility for deciding how to proceed. To avoid any possible confusion, the homes adult protection procedure must be clear, consistent and in line with current legislation. As at the last inspection not all staff have as yet undertaken training in adult protection issues, and staff spoken to demonstrated only a limited understanding of their roles and responsibilities with regard to adult protection. It is required that all staff who work in the home, including any administrative and domestic staff, undertake adult protection training as appropriate. There was evidence that service users legal rights are protected, for example all service users are on the electoral register, and service users spoken to informed the inspector that they are able to vote in elections. Ashcroft Rest Home DS0000007230.V353844.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 and 26. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that the home is suitable to meet its stated purpose with regard to its physical environment. The home was generally well maintained, and service users have access to adequate private and communal space. EVIDENCE: The home is located in a quiet residential area of Leytonstone, in the London Borough of Waltham Forest. The home is close to shops, transport links and other local amenities, and is in keeping with other homes in the area. The home consists of two terraced houses that have been converted in to one, and is built over two floors. Ashcroft Rest Home DS0000007230.V353844.R01.S.doc Version 5.2 Page 18 The communal areas consist of two lounges, a conservatory, a kitchen, dining area and well maintained garden, with appropriate garden furniture. However, both in the front and rear gardens there were discarded items that must be removed, including panes of glass, wooden planks and discarded furniture, and this must be removed. The homes utility room is located in the cellar, and laundry facilities are appropriate to the size of the home. The home was generally well maintained, both internally and externally. Furniture and fittings in communal areas were generally well maintained, and domestic in character. The home has toilets and bathrooms in sufficient numbers to meet service users needs, and these have been adapted to make them accessible to all service users. Bathrooms were clean and tidy, and free from offensive odours. Since the previous inspection the home has fitted new impermeable floor coverings to bathrooms and toilets. It was noted that all but one of the bathrooms have working locks fitted, which include an emergency override device, however, there was no lock fitted to the ground floor toilet leading off from the sitting room, and this must be addressed. The home has eleven single bedrooms, and two double bedrooms. Bedrooms have been decorated to service users personal tastes, for example with family photographs, and were homely in appearance. Bedrooms had adequate natural light and ventilation, and all have central heating. Heating appliances are appropriately boxed in. Bedrooms meet NMS on size requirements. Some bedrooms contain an ensuite toilet, and all have hand basins in them. Bedrooms contained adequate furniture, including table and chairs, wardrobes and chest of draws. At the previous inspection requirements were made that the home provide screening in double bedrooms, that all bedrooms are free from offensive odours, and that dirty bedroom carpets must be cleaned or replaced. The inspector was pleased to note that all of these issues have been appropriately addressed. It was also found at the last inspection that emergency call points were not working, and this too has been addressed. There was evidence that the home has taken steps to help prevent the spread of infection, for example hand washing facilities are situated around the home, and protective clothing such as gloves and aprons are available to staff. Various adaptations have been made to help make the home more accessible to service users, thus helping to meet their needs around equality and diversity issues. Toilets and baths have been adapted to make them more accessible to service users, and there is a chair lift to the first floor. A considerable amount of work has been done to the homes environment since the previous inspection. As mentioned, new floor covering have been installed in bathrooms, and new carpets have been fitted in communal areas and bedrooms. Communal areas have been painted, as have most of the bedrooms. The inspector was pleased to note that service users were involved in choosing this new décor. Ashcroft Rest Home DS0000007230.V353844.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that the home is staffed in sufficient numbers to meet the needs of service users, and that staff have a good understanding of their roles and responsibilities. However, the home must ensure that all appropriate pre-employment checks are carried out for staff. EVIDENCE: The home provides 24-hour staff support, including waking night staff and an emergency on-call procedure. There was a staffing rota on display, which accurately reflected the staffing situation on the day of inspection. However, as at the last inspection it did not identify who was in charge of the home at any given time. This is required so that at all times there is a member of staff on duty who has the responsibility to take any decisions that may need to be made, and that all staff on duty are aware of whom that person is at any given time. Through observation and discussion there was evidence that staff have built up good relations with service users, and that they had a good understanding of Ashcroft Rest Home DS0000007230.V353844.R01.S.doc Version 5.2 Page 20 service users needs. Staff interaction with service users was seen to be friendly and respectful, and where service users made it clear they wished to be left alone, staff were seen to respect this. Of the thirteen care staff currently employed at the home, five have successfully completed an NVQ Level 2 in Care or equivalent qualification (although the manager informed the inspector that several more staff are presently working towards such a qualification). It is required that at least 50 of care staff employed at the home have such a qualification. Records are maintained of staff training, recent training has included infection control, fire safety and medication. Several staff are booked to attend a dementia training course in late November 2007. The home has various employment related policies, for example on equal opportunities and recruitment and selection. However, the home did not have a disciplinary procedure, and this must be addressed. The inspector checked staff employment records. These were found to contain CRB checks and proof of ID, such as passports. However, they did not all contain two written references, and it is required that the home obtains two written references, (with one preferably from their most recent employer) for all staff working at the home. Ashcroft Rest Home DS0000007230.V353844.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,36,37 and 38. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that the homes manager is suitably qualified and experienced to manage a registered care home, and that appropriate health and safety checks are in place. EVIDENCE: The homes manager has many years experience of working in care, and has managed the home for the past eighteen years. They are a registered nurse, and informed the inspector that they are close to completing the Registered Managers Award. Staff and service users informed the inspector that they Ashcroft Rest Home DS0000007230.V353844.R01.S.doc Version 5.2 Page 22 found the manager to be approachable and accessible, and staff were observed to interact with the manager in a relaxed manner. Record keeping within the home has generally improved since the previous inspection, although as mentioned there is still room for improvement around care plans, risk assessments and medication records. Policies checked were of a generally satisfactory standard, but again, the adult protection policy needs further amendments, and the home does not have a disciplinary procedure. Other policies, including medication and admissions were seen to be satisfactory. Staff supervisions, care plan reviews and service user meetings all contribute to the quality assurance within the home. Copies of previous inspection reports were available to view in the home. However, the home does not have a system in place for routinely receiving feedback from service users or their relatives (such as questionnaires). Such a system must be implemented, to help inform future planning. Since the last inspection staff now receive regular formal supervision from the homes manager. Records are maintained, and staff have access to their own supervision records. Records indicated discussions around training needs and service user issues. Fire extinguishers are situated around the home, these were last serviced in February 2007. Fire alarms are tested weekly, and were serviced on the day of inspection. Regular fire drills are now held since the previous inspection. The home tests hot water temperatures on a weekly basis. The home had in date safety certificates for gas safety, PAT testing and electrical installation. The home had in date employer’s liability insurance cover. Ashcroft Rest Home DS0000007230.V353844.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 2 3 2 3 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X X 3 3 3 Ashcroft Rest Home DS0000007230.V353844.R01.S.doc Version 5.2 Page 24 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 OP28 Regulation 18 Requirement The registered person must ensure that at least 50 of care staff employed at the home has an NVQ Level 2 in Care or equivalent qualification. (Timescale 25/05/07 not met) The registered person must ensure that comprehensive risk assessments are in place for all service users, covering all areas of potential risk to themselves and others, and that these are subject to regular review. (Timescale 31/08/07 not met) The registered person must ensure that it has an adult protection procedure, which is in line with current legislation. (Timescale 31/08/07 not met) The registered person must ensure that all staff undertake appropriate training in adult protection issues, and that they have a good understanding of their roles and responsibilities with regard to adult protection issues. (Timescale 31/08/07 not met). Timescale for action 29/02/08 2. OP7 13 31/12/07 3. OP18 13 31/12/07 4. OP18 13 29/02/08 Ashcroft Rest Home DS0000007230.V353844.R01.S.doc Version 5.2 Page 25 5. OP27 17 6. OP29 19 7. OP7 15 8. OP9 13 9. OP15 13 10. OP19 23 11. OP21 23 12. OP29 18 13 OP33 24 The registered person must ensure that the staffing rota clearly indicates who is in charge of the home at any given time. (Timescale 30/06/07 not met) The registered person must ensure that all documentation required by Schedule 2 of the Care Homes Regulations 2001 is in place for all staff, including references. (Timescale 31/08/07 not met) The registered person must ensure that comprehensive care plans are in place for all service users, covering all areas of need, and that these are subject to regular review. The registered person must ensure that all prescribed medications in the home are administered and recorded as appropriate. The registered person must ensure that all fridges in the home used for the storage of food or medications is maintained at a temperature of between 2 and 8 degrees centigrade. The registered person must ensure that discarded items of furniture and building materials are removed from the homes garden. The registered person must ensure that all bathrooms and toilets in the home are fitted with a working lock, which includes an emergency override device. The registered person must ensure that the home has a comprehensive disciplinary procedure in place. The registered person must ensure that the home has a quality assurance system in DS0000007230.V353844.R01.S.doc 30/11/07 31/12/07 31/12/07 30/11/07 30/11/07 31/12/07 31/12/07 31/12/07 29/02/08 Ashcroft Rest Home Version 5.2 Page 26 place, which includes seeking the views of service users and relatives, to help inform future planning. 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 Rest Home DS0000007230.V353844.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ashcroft Rest Home DS0000007230.V353844.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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