Inspection on 24/11/06 for Ashcroft Rest Home

This inspection was carried out on 24th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 01/11/07

Ashcroft Rest Home 24/04/07

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 Yemi Adegbite Unannounced Inspection 24th November 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ashcroft Rest Home, DS0000007230.V321087.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.V321087.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 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.V321087.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th June 2006 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. Some bedrooms have a small en-suite providing toilet and hand washing facilities. There is a stair lift available on one set of stairs with a separate staircase for those who are more mobile. Because of the configuration of the building the home would not be suitable for wheelchair users. There is a rear garden available and accessible to residents with support of staff. Ashcroft Rest Home, DS0000007230.V321087.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was unannounced inspection undertaken by one inspector. It started at 10.00am and took place over 5 hours. One of the named registered provider was available throughout the visit to aid the inspection process. The main focus of this inspection was to access the implementation of the requirements and recommendation of the previous inspection. The inspector spoke with service users, a relative, members of staff and one of the registered proprietor (the registered manager was unavailable throughout this inspection). The inspector conducted a tour of the building and a number of records were inspected. There have been seven requirements and two recommendations made following this inspection. An unannounced inspection gives the Commission an opportunity to assess the home against National Minimum Standards applicable to the service without the home having notice of the visit. A number of requirements were made at the last inspection seven of which have not been met and have been restated in this report with a new timescale for compliance. Unmet requirements impact on the welfare and safety of service users. Failure to comply by the revised timescale will lead to the Commission for Social Care Inspection considering enforcement action to secure compliance. Verbal feedback was given to the registered proprietor at the end of the inspection. The inspector wishes to thank the staff and service users for facilitating this unannounced inspection and actively contributing to the regulatory process. What the service does well: Service users spoken to, who were able to express a view, were very happy with the quality of care they were receiving in the home. There is a very relaxed atmosphere in the home and residents appear unhurried and are given sufficient time and support in their everyday activities which was observed throughout the inspection. A relative spoken to during the inspection also expressed satisfaction with the service provided. Staff were seen to be working effectively as a team throughout the inspection, with staff interacting well, both with each other and the residents. Ashcroft Rest Home, DS0000007230.V321087.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ashcroft Rest Home, DS0000007230.V321087.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.V321087.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, 3, &5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has relevant documentation to ensure that prospective service users have the information they need to make an informed choice about where to live. Prospective service users and their relatives have a choice of visiting the home prior to admission. However There was no evidence to indicate that appropriate pre-admission assessments details had been obtained from other professionals/placing authority prior to the service users moving into the home. Standard 6 was not applicable for assessment, as the home does not provide intermediate care. Ashcroft Rest Home, DS0000007230.V321087.R01.S.doc Version 5.2 Page 9 EVIDENCE: The home has appropriate documentation in place to enable prospective service users to make an informed choice about where to live and service users have the opportunity to visit the home prior to admission. Prospective service users and their representatives can visit the home for a pre-arranged or impromptu visit. A relative spoken to during the course of the inspection stated that a visit to the home was undertaken prior to the admission of their relative. The inspector viewed the home’s Service Users Guide and the Statement of Purpose, which were appropriate and contained the relevant information as required by the National Minimum Standards. These documents would assist any prospective service user to make an informed choice about the home prior to admission. Two service users have been admitted since the previous inspection in June 2006. Although the home had carried out its own initial assessment process for each of the service users, which includes areas such as personal hygiene, eating and drinking and mobility, there was no evidence that the home had obtained relevant information from the placing authority before the admission process into the home. Furthermore, there was no written evidence of whether the home can meet the need, nor that this is confirmed to the prospective service users and /or their relatives. This was a requirement from the previous inspection report, which will be restated at this inspection with a new timescale. The inspector spoke to a relative of one of the most recent service user admitted into the home who confirmed that a visit was made to the home prior to admission. Ashcroft Rest Home, DS0000007230.V321087.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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care plans were not comprehensively assessed and at times not signed to indicate involvement between service users or their relatives. Additionally there was no evidence of systematic reviews of care. There are some inconsistencies in the recording and administration of medication, which may result in unsafe practices. Staff must ensure that medication administration records are correctly completed in order to safeguard service users. EVIDENCE: Individual Care Plans are available which are easily accessible and nicely presented. However considerable portions of the Care Plan remains incomplete, with areas that could potentially place residents at risk for example medical report of the service user. Ashcroft Rest Home, DS0000007230.V321087.R01.S.doc Version 5.2 Page 11 The inspector randomly checked four service users care plans. The home has a comprehensive care plan system in place, which includes detailed assessments and individual plans to meet personal and care needs. However it was disappointing to note that examination of these care plans showed that some vital sections of had not been completed, regular reviews of care are not held and some care plans were not dated to indicate when the follow up review is to take place. Additionally the care plans seen were not signed by service users to indicate their involvement or that of their representatives. The proprietor stated that no service users are able to mange their own medication however the home would facilitate this if required. It was positive to note that a previous requirement in regards to hand written entries on the MAR sheet was met. However there were further issues observed during this inspection, which must be rectified to ensure the safety and wellbeing of service users are met. Examination of medication administration sheets had gaps where staff had not signed to indicate whether medication had been given or not. Also a service user on ‘Amoxicillin 250mg’ had two of her medication missing and unaccounted for. The inspector also observed a member of staff administering medication to a service user of 2.00pm instead at 12noon as clearly stated on the MAR sheet. There is a relaxed atmosphere in the home and residents appeared unhurried and are given sufficient time and support in their everyday lives. During the tour of the home it was observed that staff interacted well with service users and treat them with respect for example around mealtimes and providing personal care. A service user spoken to stated that she was happy at the home and staff treated her with dignity and respect. Ashcroft Rest Home, DS0000007230.V321087.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users and their representatives benefited from the home’s flexible visiting approach. Residents did have some choices and control over their lives. However there was little evidence of leisure activities within the home therefore the manager must make arrangements for a range of meaningful activities to be undertaken. Meals are nutritious and balanced and offer a healthy and varied diet. EVIDENCE: Although the proprietor stated that activities take place regularly, there was little evidence of this in the individual care plans inspected. All service users apart from one were at home sitting in the lounge on the day of the inspection and there was no evidence of any activities taking place. It was only after several hour of being at the home and a comment from the inspector that the staff put on the radio in the lounge. Staff within the home must be more Ashcroft Rest Home, DS0000007230.V321087.R01.S.doc Version 5.2 Page 13 proactive in this area to ensure that service users have access to a range of activities. The proprietor stated that armchair exercise takes place every Wednesday, which is conducted by an external provider. However this could not be verified, as there was no entry in the daily log for several weeks to indicate this activity takes place and staff on duty could not verify her last attendance date. The proprietor was advised to ensure that the care planning process includes and identifies activities and leisure interests that service users would like to pursue. The home offered flexible visiting hours for the friends and family of service users. A relative was observed to be able to spend time with the service user and looked relaxed in the home. The inspector spoke to the relative during the inspection and she stated that her family were always made welcome and are satisfied with the level of care provided. The inspector saw the home’s menu, which contained varied and well-balanced meals. There was no evidence to verify that service users have been involved in the menu planning or that they were offered a choice. Staff spoken to during the inspection stated that the registered manager undertakes the planning of the menu. The lunchtime meal is the main meal of the day, which is cooked by members of staff on duty in addition to their other responsibilities such as providing personal care, laundry and domestic duties. The staffing level was of great concern, which will be covered in detail under the staffing section. Fish, chips and peas was served to all service users on the day of the inspection, though the proprietor stated that if a resident did not like what was on offer other choices were available. The proprietor was therefore advised that choice of meals should be reflected on the menu. The inspector positively noted staff respecting the wishes of a service user in regards to her mealtime. The proprietor stated that relatives/ representatives manage all of the service users financial affairs. The home however has responsibility for the personal allowances of a number of service users, which is securely maintained. Relatives also act as advocates in most cases but advocacy services can be arranged as required. Ashcroft Rest Home, DS0000007230.V321087.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The inspector is concerned that the home was unable to demonstrate by its policy, procedure or record keeping that service users are safeguarded from abuse. The registered manager must ensure there is a vulnerable adult procedure in place to ensure that the people living in the home are protected from abuse. Staff could not locate the complaints book or any of the policies and procedure required. EVIDENCE: It was of great concern that all of the policies and procedures required to ensure the safety and wellbeing of services users were unavailable for inspection. The registered manager stated on the phone that all of the policies and procedures were updated and stored on a hard disk, but unfortunately was accidentally deleted. Additionally staff on duty were unaware of the home’s complaints book and unable to locate it, they stated that the manager deals with complaints. Ashcroft Rest Home, DS0000007230.V321087.R01.S.doc Version 5.2 Page 15 The staff on duty had some awareness of adult protection procedures and they demonstrated some understanding of their responsibilities to report any adult protection concerns. However it is the inspector’s view that staff knowledge and understanding could be further enhanced as both members of staff spoken to were unaware of the whistle blowing policy and other organisations to report concerns to for example Commission for Social Care Inspection. The registered manager must therefore ensure that the complaints policy is up-todate and available at all times. It is recommended that the home obtain the local authority Adult Protection procedures and provide staff with refresher training regarding the protection of vulnerable adults. Examination of care plans and accident records identified that not all accidents to service users are recorded as required with sufficient details and any follow up action. For example an incident, which occurred on the 10/11/06, was not appropriately dealt with. Additionally there was no evidence to indicate what lines of action were taken in regards to a service user who suffered several falls over the past two months. The registered manager must make appropriate referrals as and when required to ensure the health and wellbeing of service users. The inspector noticed that a service user had sustained an injury to her forehead. Further assessment of the accident book indicated that the front door was left open by a member of staff and the service user wandered out of the home for several hours without being noticed. The service user fell in the street and sustained a cut to her forehead. The Commission was not informed of this incident nor was there any risk assessment in place to ensure the reoccurrence of this incident is prevented. The proprietor was advised to ensure that any significant event in the home which might affect the wellbeing of the service users are reported to the Commission in line with Regulation 37 of the Care Homes Regulations. The proprietor stated that relatives manage service users finances. Ashcroft Rest Home, DS0000007230.V321087.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,23, &26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is clean and there were no unpleasant odours on the day of the inspection. However where rooms are shared, the manager must ensure that written consent of the service users or their representatives is obtained and documented. EVIDENCE: Ashcroft Rest Home comprises two adjacent buildings constructed into one relative building; fourteen service users currently reside at the home. There are eleven single rooms and two double bedrooms; rooms inspected looked personalised and contained most of the facilities required in the National Minimum Standards. The communal areas comprised a sitting room, main dining area, main lounge, a smaller lounge and a small garden to the rear. Service users were observed to move freely around the communal areas. Ashcroft Rest Home, DS0000007230.V321087.R01.S.doc Version 5.2 Page 17 On the day of the inspection all areas of the home were found to be clean, tidy and with no offensive odours. All of the bedrooms were seen by either invitation of the service user, or with permission. However it was noted by the inspector that the carpets in both rooms 7 and 13 were dirty and stained. The registered manager must therefore ensure that these carpets are either cleaned or replaced. The proprietor could not demonstrate that the home had obtained consensual agreement from service user or their relatives where rooms are shared. It was observed by the inspector that two unrelated service users shared the double bedroom on the ground floor. There was no evidence in place to demonstrate that both service users involved have made a positive choice to have a shared bedroom. It is required that where rooms are shared, they are occupied by service users who have made a positive choice to share with each other. Written consensual agreement must be obtained from the service users or their representatives and documented in the individual files. Service users have sufficient and suitable lavatories and washing facilities, which were suitably equipped with adapted equipment suitable for service users who are immobile or have restricted mobility. Ashcroft Rest Home, DS0000007230.V321087.R01.S.doc Version 5.2 Page 18 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&30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staffing levels are unsatisfactory, the level of the staff on duty are insufficient to meet the individual assessed needs of the service users. The rota needs to reflect all the staff that works in the home, including the deputy manager and all the hours worked by each member of staff. The registered manager must ensure that there are clear training schedules for staff. Additionally staff must be appropriately supervised. The procedures for the recruitment of staff are robust and provide safeguards for people living in the home. EVIDENCE: It was disappointing to note that after two separate requirements highlighting the staffing level, the situation still remains the same during this inspection. The responsible person(s) must therefore ensure that the staffing level is immediately reviewed with a report sent to the Commission for Social Care Inspection on how this is to be achieved. Failure to comply with this requirement would result in an enforcement action. Ashcroft Rest Home, DS0000007230.V321087.R01.S.doc Version 5.2 Page 19 At the start of the inspection there were three care staff on duty in addition to one of the registered providers. The home has a relatively stable staff team and effective team working was observed and evidenced throughout the inspection. Staff interacted well, both with each other and residents. The home employs twelve permanent members of staff. One member of staff spoken to was familiar with the service users and the daily routine of the home. The other member of staff was relatively newly employed with relevant experience, which should enable him to carry out his duties and responsibilities. Examination of the staff rota did not accurately reflect the staff on duty. It was also evident from the rota that at times only two members of care staff are on duty instead of the three required. Staff spoken to also confirmed that this was the case. The proprietor stated that the home has a newly appointed deputy manager who works Monday – Wednesday, however this could not be verified as there was no documentation in place and he was not reflected on the rota. It was the view of the inspector that the home was understaffed on the day of the inspection. Staff were observed to be constantly on their feet and were unable to offer one to one care or offer any activity to the service users. Staff spoken to stated that they did not have the time to spend with the service users due to the level of their duties, which include providing personal care, preparation of the main meals laundry and domestic duties. In order to ensure that adequate care is provided, more staff are required to meet the needs of service users. A member of staff who had been on the early shift was made to stay on at the end of her shift due to the fact the home would have been dangerously understaffed with only one member of staff, which could have endangered the welfare, and safety of all the service users. There was no evidence to indicate that staff receive an appropriate level of supervision, additionally there was no training schedule to specify training attended by staff. The registered manager must ensure that there are clear training schedules for staff, which meets National Training Organisation targets to enable staff to fulfil the aims of the home and to ensure that the changing needs of service users are met. Additionally staff must be appropriately supervised at least six times per year. It was however positive to note that all the relevant information required in line with the National Minimum Standards had been obtained in regards to the newly employed member of staff. These were found to be in good order with necessary references; criminal records bureau disclosures and application forms duly completed. Ashcroft Rest Home, DS0000007230.V321087.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area was not tested however it would be tested fully at the next inspection. EVIDENCE: These standards were not tested on this occasion due to the absences of the registered manager and the inability of staff and the other proprietor to locate documentation and evidence required. It is therefore required that there are clear lines of management accountability within the home in the absence of the registered manager. There are several unmet requirements from the previous two inspections. Unmet requirements impact on the welfare and safety of residents, therefore continued failure to meet repeated requirements will lead to the Commission for Social Care Inspection considering enforcement action against the registered person(s). Ashcroft Rest Home, DS0000007230.V321087.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 2 X 3 X 2 X X 3 STAFFING Standard No Score 27 1 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X X Ashcroft Rest Home, DS0000007230.V321087.R01.S.doc Version 5.2 Page 22 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 OP7 Regulation 15 Requirement Timescale for action 25/05/07 2. OP9 13 3. OP14 12 4. OP15 16 The registered manager must ensure that care plans are comprehensively assessed with all section filled in including the next review date. All care plans must be appropriately reviewed. The registered manager must 30/03/07 ensure that medication administration records are correctly completed in order to accurately document whether medication has been given or not. Service users must be given the 25/05/07 opportunity to make decisions about their daily lives and to participate in stimulating activities according to their needs and wishes. Outstanding from the last inspection Outstanding from the last inspection (Timescale 31/08/06 not met). Service users must be offered 30/03/07 choice at meal times so that they can actively decide what they wish to eat. Outstanding from the last inspection Outstanding from the last DS0000007230.V321087.R01.S.doc Version 5.2 Ashcroft Rest Home, Page 23 5. OP16 17 6. OP18 37 7. OP24 23 8. OP26 16 9. OP27 18 10. OP28 18 11. OP30 18 12. OP36 18 inspection (Timescale 31/08/06 not met). The registered manager must ensure that the complaint procedure and the adult protection policy are updated and available in the home at all times. It is required that the Commission is notified of any significant event in the home in accordance with Regulation 37 of the Care Homes Regulations. The responsible person(s) must ensure that where rooms are shared, written consent of the service users or their representatives must be obtained and documented. The responsible person(s) must ensure that the carpets in room 7 and 13 are either cleaned or replaced. There must always be a sufficient number of staff on duty, including ancillary staff, to meet the health, social and recreational needs of the residents. Outstanding from the last inspection (Timescale 31/05/06 and 31/08/06 not met). The registered person must ensure that at least 50 of care staff has an NVQ qualification by the year 2005. The registered manager must ensure that there are clear training schedules for staff, which meets National Training Organisation targets to enable staff to fulfil the aims of the home and to ensure that service users changing needs are met All staff must receive supervision as laid out in National Minimum Standards. Records of DS0000007230.V321087.R01.S.doc 25/05/07 30/03/07 30/03/07 25/05/07 30/03/07 25/05/07 25/05/07 25/05/07 Ashcroft Rest Home, Version 5.2 Page 24 13. OP37 17 supervision must be kept. Outstanding from the last inspection Outstanding from the last inspection (Timescale 31/05/06 and 31/08/06 not met). The registered manager must ensure that all the policies and procedures required by legislation are appropriately kept in the home to ensure the safety and protection of service users and staff. 25/05/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP12 OP30 Good Practice Recommendations It would be of benefit to the residents if an activity coordinator were appointed. The home is recommended to establish individual training profiles for staff, listing their current qualifications and training, proposed future training and highlighting when ‘refresher’ training is needed. It is recommended that the home obtain the local authority Adult Protection procedures and provided staff with refresher training regarding the protection of vulnerable adults. 3. OP37 Ashcroft Rest Home, DS0000007230.V321087.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection East London 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.V321087.R01.S.doc Version 5.2 Page 26 - 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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