Inspection on 29/05/08 for Ashcroft Rest Home

This inspection was carried out on 29th May 2008.

CSCI found this care home to be providing an Adequate 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 Rest Home 01/11/07

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 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Ashcroft Rest Home 27-29 Chadwick Road Leytonstone London E11 1NE Lead Inspector Rob Cole Unannounced Inspection 29th May 2008 09:00 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.V364535.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.V364535.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 Dementia (5), Old age, not falling within any registration, with number other category (15) of places Ashcroft Rest Home DS0000007230.V364535.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - Code OP (maximum number of places: 15) 2. Dementia - Code DE (maximum number of places: 5) The maximum number of service users who can be accommodated is: 15. 1st November 2007 Date of last inspection 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, transport links, 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. Ashcroft Rest Home DS0000007230.V364535.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 1 star. This means the people who use this service experience adequate quality outcomes. This inspection took place on the 29/05/08 and was unannounced. The inspector had the opportunity of speaking with service users, staff from the home, and the homes manager was present for part of the inspection, while the deputy manager was present throughout the course of the inspection. A relative of one of the service users visited the home during the course of the inspection, and the inspector was able to have a discussion with them. The inspection also included an examination of records and other documents, along with a tour of the premises. The inspector had the opportunity of observing staff carrying out their duties, including interacting with service users. Prior to the inspection, the home completed an Annual Quality Assurance Assessment (AQAA) at the request of the CSCI. Surveys were also sent out by the CSCI to both service users and their relatives. All of this was included in the overall inspection process, and has contributed to the judgments made within this report. What the service does well: What has improved since the last inspection? There have been improvements to the home since the previous inspection, and seven of the thirteen requirements set at the last inspection were found to have been met at this inspection. The home now has all necessary employment checks in place for staff, and over 50 of the staff team now have a relevant care qualification. The garden is now free from building materials and discarded furniture, and appropriate quality assurance systems are now in place. Ashcroft Rest Home DS0000007230.V364535.R01.S.doc Version 5.2 Page 6 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.V364535.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.V364535.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 inspectors judgement that service users are provided with sufficient information about the home before making a decision as to move in or not. This information is provided through written documentation, and the opportunity of visiting the home. EVIDENCE: The home has a Statement of Purpose and Service User Guide in place. Both documents are dated, and written in plain English. The Statement sets out the philosophy of care in the home, and states that “All service users have the right to maintain maximum independence . . . all service users have the right to their dignity . . . all service users will be shown respect from all those Ashcroft Rest Home DS0000007230.V364535.R01.S.doc Version 5.2 Page 9 involved in their care.” The Statement also includes details of the facilities and services provided, and of the organisational structure of the home. As with the Statement of Purpose, the Service User Guide contains all information required by the National Minimum Standards (NMS) and is subject to regular review. All service users are provided with their own copy of the Guide. It includes details of the homes physical environment, and of the homes complaints procedure. Along with the Service User Guide, all service users are also provided with a written contract/statement of terms and conditions. Contracts have been signed by the homes manager and the service user (or their representative where appropriate). Contracts include details of fees payable, what the fees cover and what is extra, along with terms and conditions of residency in the home. Although there have been no new admissions to the home since the last inspection, the home does have an admissions procedure in place. This states that the home will carry out an assessment of service users needs prior to them moving into the home, and that service users will be able to visit the home before making a decision as to move in or not. A relative who was visiting the home during the course of the inspection confirmed that the service user they were visiting had indeed been given this opportunity. Service users will initially move in on a trial basis, after which a placement review meeting is held. The procedure covers planned and emergency admissions. The home does not provide intermediate care. Ashcroft Rest Home DS0000007230.V364535.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. The inspector was satisfied that the home is generally meeting the personal care needs of service users. In order to ensure that health care needs are met, the home must ensure that medications are appropriately recorded and administered. EVIDENCE: Individual care plans are in place for all service users. These are drawn up with the involvement of the service user, care staff and the homes manager. There was evidence that service users have an annual review of their care in conjunction with their placing authority, which feeds into the care planning process. Plans are set out on a standard pro forma, which contains set headings, and staff provide further information according to these headings. Ashcroft Rest Home DS0000007230.V364535.R01.S.doc Version 5.2 Page 11 Care plans are strong on some areas, for example around personal care and mobility. However, in other areas care plans still require further development. For instance, the care plan pro forma includes the heading “Cultural and spiritual needs.” While this is appropriate, the information provided is not always as comprehensive as it should be, for example on one care plan under this heading it merely said “African-Caribbean.” Another care plan said that the service user has dementia, but again, no information was provided around what their needs are around them having dementia, or how the home was able to meet those needs. It is a repeat requirement that comprehensive care plans are in place for all service users, covering all areas of need, including information on how the home is meeting those needs. At the previous inspection it was found that not all service users had a risk assessment in place. The inspector was pleased to note that this situation has now been rectified. However, as with the care plans, risk assessments still need some further development. Assessments identify any risks, for example around mobility, diet and personal care, and usually include strategies to manage and reduce these risks. However, assessments for two service users seen by the inspector identified that on occasions these service users exhibited challenging and aggressive behaviours. This was discussed with the manager, who outlined the steps staff take when this behaviour occurs, but this was not detailed within the risk assessments. To help ensure that all staff are knowledgeable about issues, and that they take a consistent approach, it is required that risk assessments are comprehensive, and that they include guidelines on managing any challenging behaviours that service users may exhibit. All service users are registered with a GP. Records are maintained of medical appointments. These indicated that service users have access to various health care professionals, including dentists, chiropodists and psychiatrists. However, records are not comprehensive, for instance, one service user had an annual assessment with their GP on the 1/01/08, and the records indicated that there was a need for a follow up blood test to be carried out. Yet at the time of the inspection, four and a half months later, there was no evidence to suggest that this has been arranged or taken place. It is required that the home arranges for all appropriate health care related appointments for service users. The home makes use of the Continence Advisory Service, who supply advice and continence products. Used continence products are disposed of appropriately. The home has a comprehensive medication policy in place. All staff undertake training before they administer medications. Medications are stored in a locked medication cabinet, which is kept in the office, and is taken into the lounge when medication is dispensed. However, this cabinet is free standing, and not fixed to the wall, and it is required that the medication cabinet is secured to a wall. Ashcroft Rest Home DS0000007230.V364535.R01.S.doc Version 5.2 Page 12 Records are maintained of medications entering the home, and of those that are returned to the pharmacist. No service users currently self administer their medication or are on any controlled drugs. The home maintains Medication Administration Record (MAR) charts. The inspector checked several of these at random, and found that as at the last inspection, these contained several unexplained gaps, thus making it impossible to tell if the medication had been administered as appropriate on those occasions. In order to help ensure that service users receive all medications as prescribed, the home must keep clear records of all medications administered. The deputy 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. Care plans indicate that service users are encouraged to manage their own personal care as much as possible. Service users have access to a telephone that they can use in private, and are given their own mail to open where appropriate. Screening has been provided in double bedrooms. All of this helps to promote the privacy of service users. Ashcroft Rest Home DS0000007230.V364535.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 s the inspectors judgement that the home support service users to live valued lives. Activities are provided, and the food was of a good quality, although the fridge must be sufficiently chilled to ensure food remains safe for consumption. EVIDENCE: The home provides various in-house activities. It was positively noted that on the day of inspection staff were involved in some mobility exercises and ball games with service users. Service users were observed to be fully engaged with this, and appeared to be enjoying it. London Mobility visit the home twice monthly, and provide various activities including exercises and sing-a-longs. A professional entertainment company visits every three months, and put on music and costume performances. A relative spoken to during the course of the inspection commented that “I like Ashcroft Rest Home DS0000007230.V364535.R01.S.doc Version 5.2 Page 14 the concerts, relatives are invited, and the residents really enjoy it.” A minister from a Baptist church visits, and until the recent death of a service user a Catholic priest visited, thus helping to meet equality and diversity needs around religion. The home also has a selection of large print books, again helping to meet needs around equalities and diversity issues. A list of activities on offer was on display within the home, and this includes painting and reminisance. A hairdresser visits, and staff are able to support service users with culturally appropriate hairstyles. The home holds occasional parties and BBQ’s. Service users have access to television and music. Service users are supported to go out for walks in the local park. A survey completed by a relative said they thought more activities could be provided, and the deputy manager informed the inspector that it was planned that some day trips would be arranged in the summer. Relatives are welcome at the home at any reasonable time. The inspector spoke to a service user’s relative, who said that they are always made welcome, and can see their relative in private. They expressed satisfaction with the care provided, and commented that “Auntie is always dressed nice and has her hair done the way she likes it.” Through observation and discussion there was evidence that service users have a large degree of control over their daily lives, for example when to get up and go to bed. Staff were observed to ask service users what they would prefer for lunch. Service users were observed to move freely around communal areas. Records are maintained of menus. These indicated that service users are offered a varied, balanced and nutritious diet. On the day of inspection service users were offered a choice of meatballs or pie, both served with potatoes and fresh vegetables. Mealtimes were observed to be relaxed and unhurried, and support with eating was provided in a sensitive manner. Fresh fruit was available in the home, and service users were seen to be offered drinks and snacks throughout the day. The kitchen was seen to be clean and tidy. However, it was found that on the day of inspection that the fridge used in the kitchen was 11 degrees centigrade. Records are maintained of the fridge temperature, and these evidenced that the temperature is routinely between 9 and 11 degrees centigrade. In order to ensure that food stored in the fridge remains safe for consumption, the temperature must be maintained at between 2 and 8 degrees centigrade. Ashcroft Rest Home DS0000007230.V364535.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 adequate evidence including a visit to this service. It is the view of the inspector that the home has suitable policies and procedures in place around complaints. However, to help ensure that service users are safeguarded from the risk of abuse, the home must ensure that all staff undertake appropriate training around adult protection, and that adult protection procedures are in line with current legislation. EVIDENCE: The home has a complaints policy in place. This makes appropriate reference to the CSCI and includes timescales for responding to any complaints received. A copy of the procedure was on display within the home, and all service users are provided with their own copy included within the Service User Guide. The home maintains a complaints log, although the deputy manager informed the inspector that no complaints have been received since the previous inspection. The home has a copy of the Local Authorities adult protection procedure, and also its own policy on adult protection. However, although the homes policy has been updated since the previous inspection, it is still not in line with current legislation. For example, it states that the CSCI will determine what Ashcroft Rest Home DS0000007230.V364535.R01.S.doc Version 5.2 Page 16 form any investigation into an allegation of abuse will take, yet this is the responsibility of the host Local Authority. To ensure that staff and others are clear of their responsibility with regard to adult protection issues, the homes policy must be consistent with in line with current legislation and the Local Authorities procedure. The home has drawn up a list of what staff training is needed. Whilst it is positively noted that the home has taken steps to see where there are training needs, it was also noted that this list stated that six of the current care staff urgently need adult protection training. Staff spoken to on the day of inspection demonstrated a poor understanding of their roles and responsibility with regard to this issue. For example one staff said that if a service user with dementia claimed they had been hit by a member of staff, they would not necessarily act upon this as the service user with dementia may be confused. They also said that if they witnessed the homes manager hit a service user, they would discuss this with the manager in the first instance, and if the manager said that the would not do it again, they would take no further action. It is required that all staff undertake training in adult protection, and that all staff have a good understanding of their roles and responsibilities with regard to adult protection issues, in order to help ensure that service users are protected from the risk of abuse. There was evidence that service users legal rights are protected. For example, service users are registered with health care professionals, and all service users are on the electoral register. Ashcroft Rest Home DS0000007230.V364535.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 into one, and is built over two floors. Ashcroft Rest Home DS0000007230.V364535.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. The inspector was pleased to note that since the previous inspection discarded furniture and building materials have been removed from the garden. A new path has also been built in the garden, along with a new shed, used to provide extra storage space for the home. 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, thus helping to meet needs around equality and diversity issues with regard to disability. Bathrooms were clean and tidy, and free from offensive odours. Impermeable floor coverings are in all bathrooms and toilets. Since the previous inspection all bathrooms are now fitted with a working lock, which includes an emergency override device. 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. Bedrooms all include an emergency call point alarm system, the inspector set one of these of, and staff responded within thirty seconds. Two bedroom window pains were found to have large cracks in them, and one bedroom had exposed wiring by the hand basin. These issues were brought to the attention of the homes manager, and they must be 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 stair lift to the first floor. Ashcroft Rest Home DS0000007230.V364535.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 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 staffed in sufficient numbers to meet the needs of service users, and that the staff team are suitably qualified. EVIDENCE: The home provides 24-hour support, including waking night staff and an emergency on-call procedure. There was a staffing rota on display, and this accurately reflected the staffing situation on the day of inspection. The inspector was pleased to note that since the previous inspection the rota now clearly identifies who is in charge of the home at any given time. Through observation there was evidence that staff have built up good relations with service users. Staff were often seen to interact with service users in a friendly manner, and there were example of good practice witnessed, for example around support with meal times. The staff team in part reflects the cultural background of service users. All staff are provided with a copy of their job description. Ashcroft Rest Home DS0000007230.V364535.R01.S.doc Version 5.2 Page 20 The home has relevant employment policies in place, including on equal opportunities, recruitment and selection, and since the last inspection the home now has a disciplinary procedure in place. The inspector checked several staff employment files at random, and all were found to contain appropriate documentation, including proof of ID, references and CRB checks. The AQAA supplied by the home states that 90 of care staff working in the home have now achieved a an NVQ Level 2 in care or equivalent qualification. The deputy manager confirmed that this was indeed the case. Records are maintained of staff training, these indicated that recent staff training has included fire safety, food hygiene, oral hygiene and dementia. Ashcroft Rest Home DS0000007230.V364535.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 manager is suitably qualified and experienced to manage a care home. Appropriate quality assurance systems are in place, although the home must ensure that it’s physical environment is safe for service users at all times. EVIDENCE: The homes manager has many years experience of working in care, and has managed the home for the past nineteen years. They are a registered nurse, and have completed the Registered Managers Award. Staff and service users Ashcroft Rest Home DS0000007230.V364535.R01.S.doc Version 5.2 Page 22 informed the inspector that they found the manager to be approachable and accessible, and staff were observed to interact with the manager in a relaxed manner. The home has now appointed a deputy manager since the last inspection to help with the management/administration of the home. The AQAA supplied by the home states that the home has policies in place in line with NMS. The inspector checked several policies at random, including equal opportunities, medication and recruitment and selection. With the exception of the adult protection policy as mentioned in this report, policies were found to be of a satisfactory standard. Record keeping within the home was generally of a good standard, and confidential records are stored securely. The deputy manager informed the inspector that staff and service users can access their records as appropriate. The inspector checked staff supervision records, these indicated that staff receive regular formal supervision, and that a written record is maintained. Supervision includes discussions on performance issues, training needs and service user issues. Care plan reviews and staff supervisions contribute to the quality assurance within the home, and copies of previous inspection reports are available to view. Since the last inspection the home now issues surveys to service users and their relatives to gain their feedback on the running of the home. Completed surveys seen by the inspector contained generally positive feedback, one commented that “I appreciate the patience and care staff give.” Fire extinguishers were situated around the home, these were last serviced in February 2008. Fire exits were clearly signed and free from obstruction. Fire alarms are tested weekly, and were last serviced on the 13/8/07. The home had in date safety certificates for PAT testing, electrical installation and gas safety. Hot water and fridge/freezer temperatures are checked as appropriate. The home had in date employer’s liability insurance cover in place. The home’s laundry facilities are located in the cellar, and are accessed via stairs leading down from the dining area. These stairs are step and narrow, and are behind a door which is generally kept closed and locked. It was noted during the course of the inspection that this door was left open for approximately ten minutes while a member of staff was working in the cellar, and the open door was not in sight of any staff. This was brought to the attention of the home’s manager and deputy manager. The manager informed the inspector that this should not happen, and that the door should be kept shut when not in use, as several service users in the home have dementia, and are prone to wandering, and also have poor mobility thus making them more likely to fall. It is required that reasonable steps are taken to ensure the homes physical environment is safe at all times. Ashcroft Rest Home DS0000007230.V364535.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 2 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 3 3 3 3 3 2 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 3 2 Ashcroft Rest Home DS0000007230.V364535.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 OP7 Regulation 13 Requirement 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 31/12/07 not met) The registered person must ensure that it has an adult protection procedure, which is in line with current legislation. (Timescale 31/12/07 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 29/02/08 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. (Timescale 31/12/07 not met) DS0000007230.V364535.R01.S.doc Timescale for action 31/07/08 2. OP18 13 31/07/08 3. OP18 13 31/07/08 4. OP7 15 31/07/08 Ashcroft Rest Home Version 5.2 Page 25 5. OP9 13 6. OP15 13 7. OP8 13 8. OP9 13 9. OP24 23 10. OP38 13 and 23 The registered person must ensure that all prescribed medications in the home are administered and recorded as appropriate. (Timescale 30/11/07 not met) The registered person must ensure that all fridges in the home used for the storage of food or medications are maintained at a temperature of between 2 and 8 degrees centigrade. (Timescale 30/11/07 not met) The registered person must ensure that service users are supported to attend all appropriate health care appointments. The registered person must ensure that the homes medication cabinet is secured to a wall. The registered person must ensure that cracked windows in bedrooms are replaced, and that exposed wiring in bedrooms is removed or appropriately encased. The registered person must ensure that the homes physical environment is made safe for service users at all times. 30/06/08 30/06/08 30/06/08 31/08/08 31/08/08 30/06/08 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.V364535.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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.V364535.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!