Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 25/06/07 for Ashdown House

Also see our care home review for Ashdown House for more information

This inspection was carried out on 25th 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

What has improved since the last inspection?

Risk assessments for the risks of falls and Movement and Handling have been developed and reflect current best practice. Management are planning more outings for residents in the future. A training matrix has been developed to enable management to record and review staff training needs. Further training is planned for the Safeguarding of Adults. The hall carpet and kitchen flooring has been replaced and funding has been identified to add a new shower room. Guidance has been sought from the Fire Officer regarding the use of door wedges and appropriate closing devices have been fitted. The management have taken action to address the requirements made in the recent Fire Officers report. The accident records have been reviewed to ensure that they comply with the Data Protection Act.

What the care home could do better:

New residents should have basic care plans in place as soon as possible to address specific health needs and risks. Individual plans of care should be further reviewed to ensure that they contain detailed instruction to staff about how the specific health needs of residents are to be addressed. Individual plans of care should be reviewed to ensure that all residents are assessed for the risks associated with nutrition and pressure and these should be regularly reviewed. Resident`s dependency levels should be assessed and used to calculate staffing levels. Management need to ensure that all of the appropriate clearances are always obtained before staff commence employment in the home. All staff involved in the handling of food should have access to Basic Food Hygiene training. Staff supervision should be reviewed to ensure that individual staff receive formal documented supervision at least six times a year.Accident records should be further developed to ensure that they demonstrate that appropriate and timely checks are conducted after an accident has occurred.

CARE HOMES FOR OLDER PEOPLE Ashdown House 13 Ashworth Street Daventry Northants NN11 4AR Lead Inspector Stephanie Vaughan Unannounced Inspection 25th June 2007 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 Ashdown House DS0000063536.V341671.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. Ashdown House DS0000063536.V341671.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashdown House Address 13 Ashworth Street Daventry Northants NN11 4AR 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) 01327 879276 01327 879276 ashdown.house@webandmail.co.uk S & P Group Limited Mrs Alison Margaret Aldridge Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Ashdown House DS0000063536.V341671.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No person to be admitted to Ashdown House under the category OP when there are 17 persons in total of this category already accommodated within the home. The maximum number of persons to be accommodated within Ashdown House is 17. 11th April 2006 Date of last inspection Brief Description of the Service: Ashdown House is a care home for older persons, providing accommodation and personal care for up to seventeen residents. The home is situated in the centre of Daventry and is close to shops, pubs and other local amenities. Accommodation is on two floors with the upper floor accessed by lift or stairs. There are two lounges and a dining room on the ground floor. The home offers both single and shared bedrooms some of which come with ensuite facilities. The home is situated in a residential street and has secluded gardens to the side and rear of the home and a small car park is available to visitors. Current charges range from £380.00 for a shared room per week to £395.00 for a single room per week. Additional charges are in place for hairdressing, chiropody, outings and personal items. Information about the home is provided in the form of a brochure, the Statement of Purpose document and the most recent CSCI (Commission for Social Care Inspection) inspection report are on display in the homes reception area. Residents and relatives are also advised that inspection reports can be accessed through the Commission for Social Care Inspection website. Ashdown House DS0000063536.V341671.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to this statutory inspection, a period of three hours was spent in preparation. This comprised reviewing previous inspection reports and associated requirements and recommendations; the service history, risk assessment and other documentation including the Annual Quality Assessment. No comment cards were received from residents or their representatives prior to the inspection. Since the last inspection the Commission have received no complaints or allegations about this service. The Commission have a focus on Equality and Diversity and issues relating to this are included in the main body of the report. However the existing residents are all white British with a good command of the English language. This site visit to the home was conducted over a period of six hours during which the inspector made observations and spoke to residents and staff. A limited tour of the premises was conducted which involved viewing the communal areas and a selection of the private accommodation. Case tracking is the method used during inspection where of a sample of three residents were selected and all aspects of their care and experiences reviewed, including individual plans of care and associated documentation. The Registered Manager was present for a short period during this visit. What the service does well: Admissions to the home are managed well and residents have the right information to enable them to make informed choices and decisions. Residents are involved in the care planning process and care plans are highly individualised. This ensures that the residents personal and social care needs are addressed and enables the service to meet the equality and diversity needs of residents. Residents have access to a range of health care specialists and referrals are made in a timely fashion. Medication is stored appropriately; associated records are in good order demonstrate that residents receive their medication safely. Ashdown House DS0000063536.V341671.R01.S.doc Version 5.2 Page 6 Privacy and dignity is managed well, residents were well presented and staff were seen to relate well to residents. Residents spoken to confirmed that the staff were nice to them and that their privacy was respected. Routines are flexible and varied; residents are consulted about all aspects of the running of the home including the décor, meals and activities. Residents are supported to maintain their independence. There is a varied activities programme, which includes in-house activities, visiting entertainers and occasional outings. Residents are supported to maintain their faith; they’re right to vote and to maintain relationships with friends and family. Residents are satisfied with the food provided in the home and are able to contribute to the menu planning process. A formal menu is available and offers choice at each meal, the menu is varied and reflective of the existing residents culture. Arrangements are in place to cater for special diets. Residents are able to voice their concerns and the complaints policy contains the right information. There have been no complaints during the last twelve months. Staff have the right training and know how to make sure that residents are protected from abuse. The standard of the environment is good being homely, comfortable, clean and safe. Four of the bedrooms are double; residents consent to share a double room and are offered single rooms as they become available. Arrangements are in place to replace the carpet in the main lounge, which is worn and could cause residents to trip. Staffing levels, recruitment practices and staff training are generally managed well. Residents and staff confirmed that the Registered Manager promoted a good atmosphere in the home. Residents are regularly consulted about their views and these are used to improves services. Quality assurance processes are in place to ensure that the home is safe, that systems within the home continually improve and continue to meet the needs and wishes of residents. What has improved since the last inspection? Ashdown House DS0000063536.V341671.R01.S.doc Version 5.2 Page 7 Risk assessments for the risks of falls and Movement and Handling have been developed and reflect current best practice. Management are planning more outings for residents in the future. A training matrix has been developed to enable management to record and review staff training needs. Further training is planned for the Safeguarding of Adults. The hall carpet and kitchen flooring has been replaced and funding has been identified to add a new shower room. Guidance has been sought from the Fire Officer regarding the use of door wedges and appropriate closing devices have been fitted. The management have taken action to address the requirements made in the recent Fire Officers report. The accident records have been reviewed to ensure that they comply with the Data Protection Act. What they could do better: New residents should have basic care plans in place as soon as possible to address specific health needs and risks. Individual plans of care should be further reviewed to ensure that they contain detailed instruction to staff about how the specific health needs of residents are to be addressed. Individual plans of care should be reviewed to ensure that all residents are assessed for the risks associated with nutrition and pressure and these should be regularly reviewed. Resident’s dependency levels should be assessed and used to calculate staffing levels. Management need to ensure that all of the appropriate clearances are always obtained before staff commence employment in the home. All staff involved in the handling of food should have access to Basic Food Hygiene training. Staff supervision should be reviewed to ensure that individual staff receive formal documented supervision at least six times a year. Ashdown House DS0000063536.V341671.R01.S.doc Version 5.2 Page 8 Accident records should be further developed to ensure that they demonstrate that appropriate and timely checks are conducted after an accident has occurred. 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. Ashdown House DS0000063536.V341671.R01.S.doc Version 5.2 Page 9 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 Ashdown House DS0000063536.V341671.R01.S.doc Version 5.2 Page 10 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 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service receive clear information to enable them to make a choice about whether or not they might wish to live in the home. EVIDENCE: The Statement of Purpose and Service Users Guide were reviewed and seen to contain the basic information. The Registered Manager confirmed that both these documents were currently being reviewed to ensure that they contain all of the required information. She was also able to confirm that these documents could also be supplied to prospective and existing residents in large print and different languages as required. Ashdown House DS0000063536.V341671.R01.S.doc Version 5.2 Page 11 Residents were able to confirm that they had received appropriate information prior to admission and that they or their relative had had opportunities to view the home in order for them to be able to make informed decisions as to whether they would like to live there. Residents also confirmed that they had been able to spend they day or a week in the home to experience what it would be like to live there before deciding to stay permanently. Residents confirmed that they had been assessed to ensure that the home was able to meet their needs. They were also able to confirm satisfaction with the way that their admission had been managed, that staff had been allocated to support them to settle into their new environment. The individual plans of care contained evidence that appropriate assessments had been conducted and that assessments that had been conducted by other professionals had been obtained. All residents had appropriate contracts in place. The preadmission assessments are used to form the basis of the individual plans of care, these are developed in consultation with residents and take into account their individual needs and preferences. Currently the service aims to develop the individual plans of care within one month of admission, however where specific medical needs or risk are identified basic care plans and risk assessments should be put in place as soon as the need or risk is identified. The service does not provide intermediate care. Ashdown House DS0000063536.V341671.R01.S.doc Version 5.2 Page 12 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 good. This judgement has been made using available evidence including a visit to this service. Residents have a detailed plan of care, which indicates that they are treated as individuals and that their heath care needs are met. EVIDENCE: Individual plans of care are generated from the preadmission assessment documentation and in consultation with the resident. Care plans are highly individualised and contain information about the resident’s previous lifestyle, personal and social care needs including preferred routines and individual choices. Individual plans of care demonstrate that the service supports the Equality and Diversity of residents. Ashdown House DS0000063536.V341671.R01.S.doc Version 5.2 Page 13 Individual plans of care contain basic information about the individual residents health care needs and these should be further developed to include more detailed instruction to staff about the management of specific medical conditions such as diabetes. Residents are assessed for the risk of falls and these contain the right information to reduce and manage the risks. Residents are also assessed regarding their Movement and Handling needs and associated risks. There is evidence that residents are involved in the care planning and review of the individual plans of care on a regular basis. Individual plans of care evidence that health care is generally managed well. Residents have access to a range of health care specialists including General Practitioners, Community Nursing Service, Continence, Chiropody, Dental and Ophthalmic Services. Daily records indicate that these services are accessed appropriately as the need is identified and for routine health promotion activities such as the annual flu vaccination, thus ensuring good outcomes for residents. One resident commented that ‘the staff are very good they if there is a problem they get onto the doctors straight away and sort it out’ Individual plans of care evidence that Residents are supported to maintain their independence and appropriate assistance is provided where it is needed. Individual plans of care contain good information about personal hygiene needs including oral care. There is evidence that residents are weighed on a regular basis and some evidence that residents have nutritional assessments in place, however some of these are out of date and do not reflect the current needs. The incidence of pressure ulcers is low indicating good outcomes for residents. The service accesses appropriate pressure relieving equipment through the Community Nursing Service. However there is currently no evidence that residents are routinely assessed for the risks of pressure using standardised assessment tool. The management of medication was reviewed and found to be satisfactory. Storage and stock control systems are in place and appropriate records maintained. Medication Administration Records are maintained in good order and spot checks indicated that the remaining stock corresponded with the amount prescribed and administered. Residents are assessed regarding their wishes and ability to self medicate. Ashdown House DS0000063536.V341671.R01.S.doc Version 5.2 Page 14 Privacy and dignity is managed well, residents were well presented and staff were seen to relate well to residents. Residents spoken to confirmed that the staff were nice to them and that their privacy was respected. Ashdown House DS0000063536.V341671.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have control over their lives to enable them to enjoy a lifestyle that promotes their choice and independence EVIDENCE: Individual plans of care evidenced that routines are flexible and varied. Residents confirmed that they were able to make choices about their times of rising and retiring to bed and how to spend their time during the day. Residents are consulted about all aspects of the running of the home including the décor, meals and activities programme. Residents are also supported to participate in light domestic activities should they wish to do so. There is a dedicated activities coordinator who organises a range of activities including bingo, reminiscence sessions, physical exercise and musical Ashdown House DS0000063536.V341671.R01.S.doc Version 5.2 Page 16 entertainment. There are a range of external entertainers that come to the home to provide regular entertainment. Activities are published in the newsletter and on an information board in the home. Relatives are also invited to participate. The service also organises occasional outings to local venues and aim to increase these activities within the near future. Residents are supported to maintain their faith through access to religious ceremonies such as Holy Communion. Individual plans of care evidenced that residents are supported to maintain their right to vote in general and local elections. Residents are supported to maintain contact with their family and friends, visiting times are flexible and relatives were seen to be coming and going throughout the inspection. Residents are able to bring their own possessions into the home and are supported to access their personal records such as the individual plans of care. The standard of the food is good residents contribute to the menu planning process and a formal menu is available on a daily basis. Menus indicate that residents have a good selection of food at each meal including a hot breakfast. The lunchtime service seen to comprise roast pork with apple sauce, roast potatoes with cauliflower and carrots or sweet and sour chicken with rice and bread and butter pudding for desert. Meals appeared well presented and of adequate proportion. There are also hot and cold alternatives for the teatime menu and other snacks are available at suppertime, regular fluids are available throughout the day. Residents confirmed satisfaction with the food provided. Arrangements are in place to cater for residents requiring special diets. Ashdown House DS0000063536.V341671.R01.S.doc Version 5.2 Page 17 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. This judgement has been made using available evidence including a visit to this service. There is a robust complaints procedure; good staff awareness and attitudes regarding the Safeguarding Adults so that residents feel safe and are well protected. EVIDENCE: There have been no complaints made about this service within the lasts 12 months. Residents were able to confirm that they had they right information and that they knew how to complain should they wish to do so. The complaints policy is made available to existing and prospective residents thought the Statement of Purpose. This document is also available in the main entrance and contains the right information about the complaints process. Residents were able to confirm that they felt safe living at the home and that they staff were nice to them. Staff were able to demonstrate that they had a good understanding about the types of abuse and the action that would need to be taken in the event of an allegation. Staff receive training in the Safeguarding Adults through their induction training and National Vocational Ashdown House DS0000063536.V341671.R01.S.doc Version 5.2 Page 18 Qualification in Care level 2. Further training for the Safeguarding Adults is planned for the near future. Ashdown House DS0000063536.V341671.R01.S.doc Version 5.2 Page 19 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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment is good, providing residents with a safe and comfortable place to live EVIDENCE: The home provides a comfortable and safe environment for residents. All areas are well furnished and comfortable. Appropriate safety equipment is fitted such as window restrictors and radiator guards. All areas are well ventilated and lit. Four of the bedrooms are double rooms, which provide the opportunity for married couples to share. However consent is sought from residents who are unrelated before a room is shared. Appropriate arrangements are in place to Ashdown House DS0000063536.V341671.R01.S.doc Version 5.2 Page 20 promote privacy and residents are offered single rooms as they become available. Residents are offered a key and are able to personalise to their bedrooms with their own possessions. Facilities are in place to support residents with assisted bathing needs and there are adequate supplies of hot water. The carpet in the main lounge is slightly worn and uneven which has the potential to become a trip hazard. The Deputy Manager confirmed that there are arrangements in place to replace the existing carpet in the near future. The garden area is well maintained and accessible to residents. All areas appeared well maintained clean and hygienic. Ashdown House DS0000063536.V341671.R01.S.doc Version 5.2 Page 21 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 good. This judgement has been made using available evidence including a visit to this service. The home employs appropriate numbers of inducted and trained staff to ensure that residents’ needs are appropriately met. EVIDENCE: There are currently fourteen residents living at the home and staffing levels are good. There is a formal duty rota that specifies that there are three care staff on duty throughout the day time shifts, two in the evening with one waking staff at night with one further staff member on call. The Registered Manager is also on duty during the daytime shifts of Monday to Friday. The care staff are supported by adequate numbers of catering and maintenance staff. Staffing levels are adjusted according to the needs of residents, however there is currently no formal method in place of calculating staffing levels according the assessed levels of residents dependency. Ashdown House DS0000063536.V341671.R01.S.doc Version 5.2 Page 22 Staff recruitment practices are generally good, staff files evidenced that appropriate references are obtained before staff commence employment. In general management obtain appropriate Criminal Records Bureau Clearances and povafirst checks prior to staff commencing employment in the home. However there was one staff file that evidenced that a staff member commenced employment before both the Criminal Records Bureau Clearance and povafirst was obtained. There was evidence that this staff member was supervised appropriately and the Registered Manager is mindful of the need to ensure that either povafirst or Criminal Records Bureau Clearance is received before staff can work in the home and the commencement of supervised induction training. The subsequent staff recruited all had the appropriate clearances in place before commencing employment. Staff have access to appropriate induction and other mandatory training including Safeguarding Adults, Fire Safety, First Aid, Movement and Handling, Safe Administration of Medication and Infection Control. All of the catering staff have received training in Basic Food Hygiene. However care staff are involved in the handling of food through serving or assisting residents and not all of these staff have had Basic Food Hygiene training. A training matrix has been developed to enable management to record and review staff training needs. Further training is planned for the Safeguarding of Adults. Ashdown House DS0000063536.V341671.R01.S.doc Version 5.2 Page 23 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 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ interests are enhanced through the service being run in an organised manner, which promotes their health and safety. EVIDENCE: Since the last inspection the manager has now become registered with the Commission. As such she is considered to be qualified and experienced to run Ashdown House DS0000063536.V341671.R01.S.doc Version 5.2 Page 24 the home. She has obtained the National Vocational Qualification in Care level 4 and the Registered Managers Award. Both residents and staff confirmed that the manager created an open and inclusive culture within the home. The management have established a range of activities to support quality assurance within the home. These include regular residents satisfaction surveys, the results of which are used to improve services to residents, feedback to residents is provided through individual contact, residents meetings and the service newsletters. Regular residents and staff meetings are held to discuss views about a variety of issues and areas for improvement. Other activities include regular audits of the standard of hygiene within the home, general maintenance, medication systems, accident records, individual plans of care, staff files and training. The home hold small amounts of resident’s money, this is stored safely, within individual containers and appropriate records including receipts are maintained. A spot check was conducted and found that the balance corresponded with the written records of money received and spent. Staff files demonstrated that staff supervision is in place, however there evidence that this is being conducted infrequently. Safe working practices are in place, appropriate maintenance checks are conducted. Guidance has been sought from the Fire Officer regarding the use of door wedges and appropriate closing devices have been fitted. The management have taken action to address the requirements made in the recent Fire Officers report. Staff have access to a full range of appropriate policies and procedures. New staff receive appropriate induction training and have access to other mandatory training. Risk assessments are in place for the environment and the current building work. Accident records are maintained and now comply with the Data Protection Act. However they do not currently demonstrate that appropriate and timely checks are conducted after an accident has occurred. Ashdown House DS0000063536.V341671.R01.S.doc Version 5.2 Page 25 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 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 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 2 X 3 Ashdown House DS0000063536.V341671.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 OP7 OP8 Good Practice Recommendations New residents should have basic care plans in place as soon as possible to address specific health needs and risks. Individual plans of care should be further reviewed to ensure that they contain detailed instruction to staff about how the specific health needs of residents are to be addressed. Individual plans of care should be reviewed to ensure that all residents are assessed for the risks associated with nutrition and pressure and these should be regularly reviewed thereafter. Resident’s dependency levels should be assessed and used to calculate staffing levels. Management should ensure that all of the appropriate clearances are always obtained before staff commence employment in the home. All staff involved in the handling of food should have Basic DS0000063536.V341671.R01.S.doc Version 5.2 Page 27 3. OP8 4. 5. 6. OP27 OP29 OP30 Ashdown House 7. 8. OP36 OP38 Food Hygiene training. Staff supervision should be reviewed to ensure that individual staff receive formal documented supervision at least six times a year Accident records should be further developed to ensure that they demonstrate that appropriate and timely checks are conducted after an accident has occurred. Ashdown House DS0000063536.V341671.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Ashdown House DS0000063536.V341671.R01.S.doc Version 5.2 Page 29 - 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!