Inspection on 14/06/07 for Ashdale

This inspection was carried out on 14th June 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

Ashdale 07/06/06

Ashdale 21/12/05

Ashdale 08/06/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Ashdale 235 Mottram Road Stalybridge Tameside SK15 2RF Lead Inspector Janet Ranson Unannounced Inspection 14th June 2007 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 Ashdale DS0000063124.V343028.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. Ashdale DS0000063124.V343028.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashdale Address 235 Mottram Road Stalybridge Tameside SK15 2RF 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) 0161 338 2621 0161 338 2621 Progressive Care Limited Mrs Helen Crowshaw Care Home 20 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (20), of places Physical disability over 65 years of age (4) Ashdale DS0000063124.V343028.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 20 service users to include: *up to 5 service users in the category of DE(E) (Dementia over 65 years of age). *up to 4 service users in the category of PD(E) (Physical disability over 65 years of age). *up to 20 service users in the category of OP ((Old age not falling within any other category). The service should at all times employ a suitably qualified and experienced manager who is registered with or who has a registration application pending with the Commission for Social Care Inspection. 7th June 2006 2. Date of last inspection Brief Description of the Service: Ashdale is a large Victorian detached building, located close to the centre of Stalybridge. It has been extended and adapted over the years to meet the needs of 20 older people. The aids and adaptations to meet the needs of the residents include: handrails, adapted baths and toilets, and a passenger lift. There are 18 single and one double bedroom. Four of these bedrooms also have en-suite facilities. The bedrooms are situated on different levels of the building. On the ground floor there are a lounge and dining room. Car parking is to the front of the building and there are accessible gardens to the side and rear of the house. Ashdale is owned by Progressive Care Ltd, which also runs care facilities in other parts of the country. Fees for accommodation and care at the home range from £331.75 to £356. Additional charges are also made for hairdressing and chiropody services, newspapers, personal toiletries and trips. Ashdale DS0000063124.V343028.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the key inspection, which included an unannounced site visit. The site visit took place on 14th June 2007 and covered a period of seven hours from 10:00 until 17:00. The service had previously completed an annual quality assurance assessment (AQQA) and a data set that gave the inspector certain information about the provision. From these details a selection of service users and their relatives were invited to complete a small survey setting out their comments on identified care issues. An expert by experience assisted the inspector for part of the inspection. The phrase ‘experts by experience’ is used to describe people whose knowledge about social care services comes directly from using social care services. This person talked to various residents about their quality of life. She also spoke with a relative and together with the inspector spoke with four staff. She completed a report some of which is detailed within this report. A total of four residents identified needs were closely looked at by the inspector. Individual details of their experiences and care were examined from when they first came into the home to their current care needs. The inspector looked around the building and checked a selection of staff and residents’ records. In addition top a team of carers the company employs catering, domestic staff and a maintenance person. There is also a part time activities organiser. The service has completed some of the requirements made at the last inspection What the service does well: This service provides a friendly and relaxed environment for people to live in and for those people who visit the home. The residents and a visitor were positive about the standard of care offered, and in particular about the friendly and helpful attitude of the staff team. The social activities are very well catered for. They provide the residents with stimulation and are organised by an experienced dedicated activities coordinator. The staff team are experienced, open and approachable. Ashdale DS0000063124.V343028.R01.S.doc Version 5.2 Page 6 The residents and a visitor were confident that any issues they raised would be appropriately dealt with by the manager. 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. Ashdale DS0000063124.V343028.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 Ashdale DS0000063124.V343028.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): 2, 3 & 5 Ashdale does not offer intermediate care. Quality in this outcome area is adequate. Failing to thoroughly complete an initial assessment could result in admitting people to the home with needs that cannot be met by the carers. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the last inspection the home was required to provide each resident with a contract (terms and conditions). This is to make sure the prospective resident have details of the services they may reasonably expect for the fee they are expected to pay. A copy of the homes terms and conditions was located in respect of the three residents details that were examined by the inspector. The manager must make sure that any changes to the resident’s terms and conditions are communicated as soon as possible to the residents or their representatives. Ashdale DS0000063124.V343028.R01.S.doc Version 5.2 Page 9 The home has a written policy that encourages prospective service users, or their representatives, to visit the home before making a decision to move in. The manager confirmed that prospective residents were invited to visit the home to look at the facilities and to sample a meal. Care needs assessments were contained within the three care files examined as part of the inspection. Ashdale also uses a system of assessing the potential resident’s needs that is carried out and documented by a senior member of staff. By completing such an assessment the home should be able to identify individual needs so that they can be sure the carers have the skills to meet them. In practice the document was not always completed in a thorough manner. This means that some people could be admitted to the home with needs that have failed to be correctly assessed. The manager said they always wrote to the prospective resident to inform them that there was a place for them at the home. Ashdale DS0000063124.V343028.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 adequate. A failure to consistently monitor individual health care could result in putting the resident’s health and welfare at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four care plans and associated risk assessments were examined as part of the inspection process. The care plans were based on the information contained in the initial assessment document. It should be noted that this assessment had not always been consistently carried out. The current system is in the process of being changed. It was felt that the plans as presented were generalised and not person centred. Although the home had addressed the requirements from the last inspection concerning cultural, spiritual and social needs there remained areas in the pre Ashdale DS0000063124.V343028.R01.S.doc Version 5.2 Page 11 printed document that had not been completed. Documentary evidence of service users involvement in the care planning process was inconsistent. Photographs of the residents were not always present on the plans. The care plans documented any action to be taken by the carers to ensure aspects of health, personal and social care are met and monitored. There was evidence to show that directions in one care plan had failed to be carried out. This concerned a resident who was at risk from malnutrition. The written plan was to weigh the resident at monthly intervals, which is considered to be good practice. The record showed the residents weight dropping however there was no entry for the last two months. This is indicative of a failure to review the care plans and to recognise where the plans are not achieving the desired results. Where identified, the resident’s health is monitored and addressed by the appropriate health care professionals including chiropodist, speech therapist and district nursing services. The manager noted in the AQQA they were experiencing problems in locating a community dentist. The manager confirmed this situation had been satisfactorily addressed. A short social history had been documented in the care plans examined as part of the inspection. This is good practice and especially helpful when caring for a person with dementia. A pharmacist from local Primary Care Trust (PCT) had recently carried out a full audit of procedures and practice concerning the administration and storage of all medications at the home. It is understood that the inspection identified aspects of storage that were to be discussed during a further planned visit. The home uses a monitored dosage system, which means the individual medication is put into a sealed bubble of plastic by the local pharmacist. The pharmacist also provides the medical administration records (MAR) as part of the system. The staff who are responsible for the administration of the medication have received the appropriate training to carry this out. The medication storage and observed practice was satisfactory. Based on observation, it was apparent that the staff respected the residents’ privacy by knocking and waiting before entering rooms. The carers responded to the residents in a respectful manner and in discussion demonstrated their understanding of individual needs. The expert by experience noted (the staff are) “caring and attentive to the residents needs.” Ashdale DS0000063124.V343028.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 good. An appropriate range of activities was available for service users to participate in if they wished, which recognised their religious and cultural diversity in addition to providing social stimulation. This judgement has been made using available evidence including a visit to this service. EVIDENCE: An experienced activities organiser is employed to provide stimulation to the residents. She achieves this by arranging an imaginative programme, which includes trips out of the home and involves the resident’s families and friends. A visitor told the expert by experience that a birthday party had been arranged for her relative and everyone had enjoyed it. This person went on to explain that residents and relatives meetings were held where information was exchanged and any concerns could be raised. Residents, relatives and staff enjoyed a recent trip to the Bridgwater Hall for a Glen Miller concert. A resident told the expert by experience “the concert was great.” Ashdale DS0000063124.V343028.R01.S.doc Version 5.2 Page 13 The activities organiser is also responsible for editing a newsletter that is circulated to the residents and their visitors. Copies were also available within the building. There is a monthly visit from a local church, which they supplement by a weekly visit from lay visitors. The expert by experience noted that several residents told her that they could go to bed when they wish and get up when they wanted to. A resident said, “I sometimes do not go to bed until after midnight and I feel safe here.” No menus were available for the inspector to check if the food provided was balanced and provided choice for the residents. The staff confirmed this to be the case but the cook also said she would always provide an option to the main meal if a resident did not like what was on offer. This is accepted as a resident told the expert by experience she did not like beef and always had something different. The inspector was also made aware that a person who only ate vegetables (for religious reasons) would tell the cook what she would like to eat each day. In the absence of a menu it is difficult to understand how the catering staff know what to cook and the residents know what is on offer. The expert by experience noted “all the residents seemed happy with the meals and did not feel pressured if they refused what was on offer.” Ashdale DS0000063124.V343028.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 good. The residents and their visitors are confident that any complaint they may have would be taken seriously and appropriately dealt with. The residents are safe from abuse or exploitation by the homes policies and practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Record of complaints made to the manager was examined. It was noted the last complaint had been addressed within the timescale the full details, investigation and outcome had also been recorded. The residents have access to the complaints process in their bedrooms. A resident told the expert by experience that she was aware of her right to complain and that she would speak to one of the staff if she was not satisfied with anything. There have been no concerns or issues about Ashdale brought to the attention of the Commission for Social Care Inspection. When interviewed the carers demonstrated their understanding of the requirement to protect the residents from abuse. There had been no specific training other than that provided by the National Vocational Qualification at Ashdale DS0000063124.V343028.R01.S.doc Version 5.2 Page 15 level 2. It is recommended that all the staff have access to the specific training in the protection of vulnerable adults. There have been no safeguarding adults procedures involved at Ashdale. Ashdale DS0000063124.V343028.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, 20, 23, 24, 25 & 26 Quality in this outcome area is poor Some areas in the physical environment of the home are failing to provide an acceptable level of comfort for the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A brief tour of the building and grounds was undertaken. The inspector also looked at a selection of bedrooms many of which showed clear signs of personalisation. A person has been employed since the last inspection to carryout repairs and general maintenance in the home. This person had been in post for only a few days at the time of the inspection. Ashdale DS0000063124.V343028.R01.S.doc Version 5.2 Page 17 The standards of the decoration continues to vary throughout the home. This was also noted at the last inspection (June 2006). Also at the last inspection the inspector was advised there were plans to refurbish all areas of the building. This clearly had not taken place. In two first floor bedrooms there was obvious signs of water penetration. One area, according to the manager had been repaired but had not been redecorated, whereas the other area the wallpaper was stained by damp and hanging off the wall. The expert by experience noted that her “initial impression was one of disappointment (with the environment)”. A visitor also voiced her disappointment with the lack of improvement to the environment since the new owners took over. The staff were aware of the promises to refurbish the home but had not been advised of the date when this is planned. The kitchen in particular was very poorly presented in that the units were domestic quality and had obviously not stood the test of time. Some walls were wood panelled and others partially tiled. The ceiling was covered in polystyrene tiles that are particularly dangerous in the event of fire. This gave a very bad impression and could clearly be off putting to any potential resident. The inspector understood at a recent inspection the environmental health officer had given the company three months to make improvements to the kitchen. It was confirmed by the environmental health officer this date had been renegotiated in order that a total refit can be carried out. The manager’s office is located in the basement and can only be accessed by walking through the kitchen. (The laundry is also located in the basement however the manager assured the inspector that the staff go directly into the laundry via an external door.) A further concern was identified regarding the new no smoking legislation. The two residents who currently smoke remain in the dining room. This creates a poor atmosphere for the residents to eat their meals and is far from satisfactory. The manager stated that a new area was to be provided; this Ashdale DS0000063124.V343028.R01.S.doc Version 5.2 Page 18 involved reinstating a wall to the back of the lounge (the door and a window is still there). The manager was aware of the enforcement date (July 2007) but was not able to provide a date when the service will comply with the legislation. The residents have access to a large lawned area to the rear of the building. It is safe and in the main not overlooked. The tarmac paths from the front of the building lead safely round the house and provide a level means for people in wheelchairs to enjoy the outside environment. A resident said, “I love to sit in the garden when it is sunny and the staff come and sit with me when it they have a minute.” A resident told the inspector and the expert by experience he was not satisfied with his accommodation. This was brought to the manager’s attention. It was stated that she and the resident’s social worker were both aware of this and it had been agreed that an alternative would be offered when a room became available. It was noted that there were insufficient dining chairs for all the residents to sit together at the dining tables should they choose to do so. In addition the occasional tables in the lounge were in a poor condition. In general soft furnishings were shabby. An amount of personal toiletries could be seen on a shelf in the ground floor bathroom. This is considered to be institutional practice. The home in general was clean and there were no hazards to health and safety noted during the inspection. Ashdale DS0000063124.V343028.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, 29 & 30 Quality in this outcome area is adequate. Minimum staffing levels are maintained to ensure the health and safety of service users. Lapses in mandatory training had the potential to put service users and staff at risk from poor practice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From observation during the inspection the numbers of staff on duty met with the residents’ assessed needs. A rota was available for inspection. It was confirmed that one person had left their employment, and in fact the manager interviewed a person for the post during the inspection. The majority of people working at Ashdale have done so for a long time. They are a mature group of staff who are attentive and provide care for the residents in a respectful manner. At two previous inspections it was required that the recruitment and selection processes were improved. A selection of staff files was examined. The files were well organised. They showed clear signs of improvement having been completed by the company human resources department. Each file contained the required references and police clearances. Any gaps in the employment Ashdale DS0000063124.V343028.R01.S.doc Version 5.2 Page 20 history had been checked and the outcomes documented. Evidence of identity was also in place. The inspector and the expert by experience talked with four members of staff. They confirmed they had either achieved an NVQ or where in the process of enrolling. They also said they had received the mandatory health and safety training but had not always received the required refresher training in order that their practice remains current. None of the workers had received training in infection control but did have access to protective clothing. All the staff that were interviewed by the inspector confirmed they enjoyed working at Ashdale and spoke highly of the manager. The manager had recently achieved accreditation to provide moving and handling training updates to her staff group. There were no definite plans to deliver this important training to the staff. In discussion the manager stated that she had signed up for a variety of training for the staff through the local consortium. This is a very popular training resource that gets booked up very quickly. The consortium had advised her that her staff had been placed on the waiting lists. This is not satisfactory. It is recommended the manager seeks further training resources or advice from the company training manager. Ashdale DS0000063124.V343028.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, 33, 35, 37 & 38 Quality in this outcome area is adequate. The manager is appropriately qualified but needs to be more proactive with regard to staff training and record keeping. This is so that the residents can be certain they are receiving the correct and safest levels of care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has the skills and experience to manage Ashdale she has achieved her registered managers award and has also recently attended training in the new Mental Capacity Act. There are clear lines of accountability within the organisation. The manager confirmed she receives professional Ashdale DS0000063124.V343028.R01.S.doc Version 5.2 Page 22 supervision and personal development at regular intervals via her line manager. In order that the residents are cared for in the safest manner the manager must pay greater attention to the staff training needs and to the reviewing and monitoring of the care plans. Issues out of the manager’s control are those of the environment in particular the kitchen, the poor standard of some furniture, décor and soft furnishings. A quality satisfaction assessment had been out in 2006 with “some positive feedback.” There were no known plans to repeat this process. The residents had had the statutory annual reviews completed by the local authority. Health and safety records were not examined at this inspection however the inspector was advised they were up to date. Finances systems had not changed since the last inspection when they were considered to be robust. Record keeping with regard to the residents care was in general poorly carried out and lacked robust monitoring. The homes policies and procedures were not accessible to the inspector as they were in the process of being updated and reviewed at the company head office. Ashdale DS0000063124.V343028.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 X 3 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X 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 X 18 3 2 3 X X 3 3 1 2 STAFFING Standard No Score 27 2 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 3 2 Ashdale DS0000063124.V343028.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 OP3 Regulation 14(1) Requirement In order that the service can be certain they can meet the resident’s needs they must ensure that a full assessment of completed. Individual care plans must be based on the fully completed assessment of need so that the residents have clearly identified outcomes. The manager must make certain that the care plans and risk assessments are monitored so that the residents are receiving the desired level of care. The manager must make sure a record of food is maintained so that anyone looking at it can determine if the diet meets with individual needs. The registered person must ensure that staff receive the mandatory training in health and safety practices at the required intervals. This is so that the residents are cared for in the safest possible manner. (Timescales of 01/03/06 and 01/09/06) DS0000063124.V343028.R01.S.doc Timescale for action 01/08/07 2. OP7 15(1) 01/08/07 3. OP8 15(2) 01/08/07 4. OP15 Schedule 4 (13) 01/08/07 5. OP38 13 01/09/07 Ashdale Version 5.2 Page 25 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 OP18 OP19 Good Practice Recommendations The staff should have specific training in the protection of vulnerable adults. The manager should take advice from the local environmental health department concerning arrangements to improve the environment for those residents and visitors who do not smoke, and to comply with the recent legislation. The registered person should make sure the kitchen is improved in a timely manner and according to the recent environmental health departmental advice. The registered person should devise a programme of improvements to the general environment and keep records of the dates when improvements have been carried out. 3. OP19 4. OP19 Ashdale DS0000063124.V343028.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Ashdale DS0000063124.V343028.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!