Inspection on 05/07/07 for Asher House

This inspection was carried out on 5th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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.

Other inspections for this house

Asher House 08/07/08

Asher House 02/08/06

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

CARE HOMES FOR OLDER PEOPLE Asher House Third Avenue Walton on Naze Essex CO14 8JU Lead Inspector Diane Roberts Unannounced Inspection 5th July 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 Asher House DS0000066638.V345300.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. Asher House DS0000066638.V345300.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Asher House Address Third Avenue Walton on Naze Essex CO14 8JU 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) 01255 676100 01255 852846 Sentimental Care Asher Limited Mrs Vera Francis Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Asher House DS0000066638.V345300.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 20 persons) 2nd August 2006 Date of last inspection Brief Description of the Service: Asher House is a large detached property situated in a residential area of Walton on the Naze. The home is within walking distance of the seafront and local amenities. Asher House has well maintained gardens to the rear of the building, which are only accessible to people living at the home. It also has a small garden to the front of the building that can be viewed from a number of the service users rooms. Asher House is registered for older persons who need care by reason of a physical disability. Asher House has 12 single rooms of which seven are en-suite and four double rooms of which are none are en-suite. Current fees are between £367 and £420. Asher House DS0000066638.V345300.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out as part of the annual inspection programme for this home. The deputy manager was available on the fieldwork day of the inspection with the registered manager being on leave. The inspection focused upon all of the key standards. A partial tour of the premises was undertaken. Evidence was also taken from the Annual Quality Assurance Assessment completed by the management of the home and submitted to the CSCI. 4 residents, 3 staff and 1 relative were spoken to during the inspection. Feedback was also obtained from the visiting district nursing team at the home. As the manager was on leave at the time of the inspection, requests were made to send on specific documentary evidence that the deputy manager could not locate or was not aware of. At the time of writing the report, these documents had not been received by the CSCI. This is reflected in the body of the report. What the service does well: What has improved since the last inspection? What they could do better: Care plans do not show enough detail to ensure that care is given appropriately to all residents. Residents or relatives need to be involved in their care plans and they need to be kept up to date. Asher House DS0000066638.V345300.R01.S.doc Version 5.2 Page 6 Activities for the individual need to be developed to ensure all residents’ needs are met. Some areas of the home require refurbishment and some documentation relating to the maintenance of the premises needs attention. The procedures for recruiting staff need to improve to ensure resident safety and the management need to develop their quality assurance programme further in order to make it a valuable tool that can positively affect residents’ lives. 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. Asher House DS0000066638.V345300.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 Asher House DS0000066638.V345300.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): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an assessment system in place that helps to ensure that they can meet the needs of people they admit to the home. Information available to prospective residents could be developed further. EVIDENCE: The manager has a pre-admission assessment system in place. The assessment documentation completed goes on to form part of the care plan. The manager or her deputy undertake all the pre-admission assessments. The assessments of recent admissions to the home were inspected. The assessments were seen to cover all the required areas and had been completed well, giving sufficient detail so that an informed decision could be made. Good detailed information was available on both the physical and social side of care with good family and social history in place. It is clear that time had been taken when completing the assessment and family members as well Asher House DS0000066638.V345300.R01.S.doc Version 5.2 Page 9 as the resident were involved. The home has a service user guide in place and this is given in a pack on or prior to admission. Whilst this document was seen to give good information the team may wish to review it in relation to format for their resident group as the print is small and there is a lot of written information. It was not possible to speak to any residents regarding their admission to the home. Prospective residents are encouraged to visit the home before making any decisions about admission. Asher House DS0000066638.V345300.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 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care systems at the home need to improve so that the team can evidence a proactive, resident led approach to care provision and ensure positive outcomes for residents. EVIDENCE: The team have a care planning system in place that consists of a general assessment, risk assessments and care plans in a bound book. Three care plans were inspected. Care plans were seen to be in place and related to activities of daily living. Care plans contained varying levels of detail and some indication of the residents choices and preferences but this could be improved upon to make the care plans more person centred. Many of the care plans were out of date even though they are identified as needing review every six months. Some care plans were 5 yrs old and no longer relevant. Reviews had not been carried out and from discussion with the staff team, the care interventions currently being provided are not reflected in the residents care Asher House DS0000066638.V345300.R01.S.doc Version 5.2 Page 11 plan. The team need to evidence a proactive approach to care management and the care that they are actually providing. Monthly progress reports were nearly four months out of date and did not reflect an evaluation of the care provided and effectiveness of interventions. Key worker weekly reports were seen to contain some more valuable and qualitative information on the care provided, support given and resident involvement, which would make for more positive outcomes for residents. Daily records were seen to be quite informative and generally reflected the care given. There was no evidence that residents had been able to have any input into their care plan or that there relatives had been asked instead. Relatives had signed bed rail risk assessments. The annual quality assurance assessment submitted by the management of the home states ‘ we maintain comprehensive and regularly reviewed, individual care plans with the involvement of the appropriate third parties’. Records in residents’ care plans evidence that they have regular access to specialist nurses for example, diabetes and Parkinson’s disease. The district nursing team commented that the team at the home called them in at appropriate times and always acted upon the advice that they gave. Records indicate that doctors are contacted in a timely manner. A wide range of risk assessments are in place and the forms used seen to contain detailed information. The reviewing system for risk assessments needs to be reconsidered in order to ensure that up to date information is provided on each resident. Some residents risk assessments have not been reviewed since 2000, 2004, 2005 and others are only reviewed yearly. This is a concern in especially in relation to manual handling, risk of pressure sores and nutrition. It is clear from discussion with staff and observation of residents that these are not supplying an up to date assessment of current risk and subsequent management. This must be addressed. Some risk assessments, nutritional, were noted to have been recently changed to be reviewed four monthly, but this timing should also be reviewed in relation to the changing needs of the resident and risks involved. The home currently has one resident with a pressure sore acquired at the home. The resident is being seen by the district nursing team and has the appropriate pressure relieving equipment in place. This sore is felt to relate to the overall deteriorating health of the person and the district nursing team have no concerns regarding the care of this resident. Where staff are applying cream to residents skin in relation to the prevention of soreness/pressure sores, a care plan should be in place. Records show that residents are being weighed regularly but changes do not always link into the care planning system. The home has an MDS system in place. Mar sheets were neat and prescriptions clear. Items are checked in apart from some prescriptions carried over on from the previous month. The system was checked and found to be managed well. A new controlled drug new cupboard has been installed since the last inspection. A returns system is in place and residents’ records show evidence of medication reviews. Asher House DS0000066638.V345300.R01.S.doc Version 5.2 Page 12 Residents spoken to were generally happy with the care they received and said that ‘its not too bad, it’s alright living here’ and ‘its generally ok on a day to day basis’. Residents commented that staff were good with their privacy and dignity when providing help. Interaction noted between staff and residents was friendly and respectful. Asher House DS0000066638.V345300.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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the home provides a good range of activities, they need to ensure that individual and as well as group needs are being met. The meal service at the home is satisfactory. EVIDENCE: Care planning records and assessments need to be developed and/or brought up to date in order to show that residents’ current social/personal needs are being met. Records also need to evidence a more person centred approach to residents’ choices and maintaining and developing their strengths and abilities. Residents spoken to stated that ‘staff come to get you up fairly early’ and ‘they encourage you to go to bed by ten o’clock, but you can stay up’. Residents also said that ‘you have a bath once a week – bath night, although sometimes its in the afternoon’, you can say no to a bath, but I just muck in with them’. A more resident led approach needs to be facilitated further. Some residents do have good social histories in place but this is not the case for all residents. Asher House DS0000066638.V345300.R01.S.doc Version 5.2 Page 14 Various staff at the home have a role in the activities programme. Activities include, exercise classes, singing, dancing, church services, visit to a garden centre, quizzes, ceramics, pub meals and a fete is held every year. Whilst there is a good range of activities offered the team need to ensure through assessment that individual as well as group needs are being met. Residents who commented said that ‘ I am invited to go and join in the activities but they are not everyone’s cup of tea’ and ‘I would like to go out more and see people’. Relatives and friends are actively encouraged to visit and neighbours are also invited to specific events. Lunch was observed to be a calm affair with some residents using specialist aids and being sensitively assisted by care staff. Residents are encouraged to eat in the dining room but do have choice as to where they eat. This was confirmed through observation. Menus are on the dining tables and these have recently been amended following discussion with the residents as they felt it was repetitive and choice was limited. This is positive and should continue. Staff spoken to say that the team now facilitated more resident choice than they did previously. The chef feels that she provides a good range of home produced food with fresh vegetables and this was evident in the kitchen. Records show a varied menu and that alternatives are provided. The use of some value foods in the home should be reviewed due to their nutritional content. Residents spoken to had varied comments on the food, which sometimes related to who was cooking the meal. Residents also said that ‘the food is fairly good and varied’, ‘if you wanted something special to eat they would put themselves out’ and ‘the food is normal – not bad’. Asher House DS0000066638.V345300.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 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst systems are in place to listen to residents concerns and protect their rights, further development work may encourage more feedback, develop staff and in turn ensure positive outcomes for residents. EVIDENCE: The manager has a satisfactory complaints procedure in place. This is available in the service users guide in a standard format but was not seen to be displayed around the home. This should be reviewed. The manager states in her annual quality assurance assessment that a plan for improvement over the next 12 months is to ‘improve in house display of the complaints procedure’. Records of complaints are held and none had been received since the last two inspections. The manager states in the annual quality assurance assessment that they could do better by ‘encouraging both positive and negative feedback from stakeholders’. The manager states that she ‘manages the home so as to minimise the need for complaints’. Residents spoken to had varying approaches to the issue of concerns and complaints. Some were obviously unhappy with some aspects of the home, although there were no records of this in the complaints records and other said that they did not like to raise issues for fear of upsetting people. A more open approach may be needed to ensure that the residents and relatives raise issues freely and that these are recorded at all levels. Asher House DS0000066638.V345300.R01.S.doc Version 5.2 Page 16 Compliment cards seen in the home thank the staff for their ‘kindness and care’. Information on local advocacy services is displayed in the main hall. At the current time no residents’ need to use advocacy services. An adult protection policy is in place and local guidance is also available. The manager confirms in her annual quality assurance assessment that all staff have been trained in adult protection matters. On discussing adult protection with staff, it is clear that they have an understanding of such matters but were unclear regarding contacting social services and the role they played. It would be of value to revisit this with the senior staff team. The local guidance and contact numbers should be easily available in the absence of the manager. Asher House DS0000066638.V345300.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 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A homely environment is provided for residents but this is let down by maintenance, updating and décor in some areas of the home, giving variable outcomes for residents. EVIDENCE: A partial tour of the premises was undertaken. Asher House provides a very homely environment to live in, with the lounges being particularly good. Overall the home was seen to be clean. Bedrooms were seen to be well decorated and personalised and some have doors, which lead out into the garden. The home is let down by the poor standard of the some of the carpets in the hallways and bedrooms. The bathrooms also reflect poorly on the home with the standard of fittings, old carpets and general tidiness. The manager, on her annual quality assurance assessment, did not highlight these issues as Asher House DS0000066638.V345300.R01.S.doc Version 5.2 Page 18 areas for improvement but the deputy said that non-slip flooring was being considered. One resident said that the old fashioned shower fitting in one bathroom froze you one minute and burnt you the next. Since the last inspection, some bedrooms have been decorated and a new stair lift has been installed. Standards of furnishings were acceptable and the deputy stated that the proprietors plan to replace the dining chairs to help residents remain independent and make moving of residents easier for staff. The home has a large, well-maintained secure rear garden, with good access and seating area. The deputy manager said that the team were planning a sensory garden; summerhouse and greenhouse as a couple of residents like to do the garden. Arrangements in relation to fire safety were inspected in relation to the maintenance and testing of equipment. These were found to be in order apart from inconsistent fire alarm testing. A fire safety risk assessment was completed in 2004 and a partial review of the document had been undertaken in June 2007, but not completed. This must be fully reviewed on a more regular basis. Random sampling of maintenance and safety certification for equipment and fixtures in the home was undertaken. The certificate for the electrical wiring of the home was only partly available and therefore not evidencing an expiry date, with the initial work being carried out in 2004. A complete certificate must be available. The gas safety certificate was in order but this did not cover the gas tumble drier, which should be serviced as a gas appliance. This was discussed with the deputy manager. On touring the building, it was noted that upstairs windows did not have window restrictors in place. A risk assessment must be completed and the appropriate action taken where necessary. The team has an infection control policy in place dated 2004. This should be reviewed to ensure advice is up to date. It is also recommended that the team have an up to date copy of infection control advice from the local infection control team. Asher House DS0000066638.V345300.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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing provision at the home is generally sound, but the manager needs to ensure that all the correct recruitment checks and training are in place to ensure that residents are safe. EVIDENCE: At the time of the inspection, there were 12 residents living in the home. Staffing levels provided are 3 staff am. and pm. and 1 awake and 1 asleep at night. In addition to this are the manager’s hours and ancillary staff, such as a chef and domestic. Due to incomplete pages of the annual quality assurance assessment, it is not possible to comment on staff turnover and agency staff use at the home. It is felt that the current staffing levels are sufficient to meet the needs of the residents in the home. NVQ training is encouraged in the home and 50 of the staff have achieved level 2 of this qualification. Recruitment practice in the home was reviewed and staff files sampled. It was of concern to note that one member of staff had commenced work 20 days prior to receiving a CRB check and no POVA first check had been initiated. Another file contained no CRB or POVA first check. The home must not rely on police checks from foreign countries. This must be addressed to ensure the Asher House DS0000066638.V345300.R01.S.doc Version 5.2 Page 20 safety of residents as far as possible. Other required documents were seen to be in place including identification and references. Training records and confirmation from staff, show that there is an ongoing training programme at the home which includes statutory training, for example, manual handling, health and safety, food hygiene etc. Additional training in specialist subjects is also provided and includes diabetes, infection control, skills for care leadership, falls management etc. The manager should ensure that all staff have up to date fire safety training. The manager has a staff supervision system in place that includes one to one meetings and informal weekly staff meetings. Staff confirmed this. Residents spoken to said that ‘the staff team were generally very nice, with some being more caring than others’. Others said that ‘the staff have a lot to do and don’t always have time to stop and chat’. Asher House DS0000066638.V345300.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 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager needs to develop the quality assurance systems in the home and ensure that feedback is sought from residents, relatives, staff and visiting professionals so that the outcomes for residents are optimised. EVIDENCE: The manager, who is a nurse, has worked at the home some years and has the Registered Managers Award. The manager is primarily office based but staff report that she does help out when required. The staff speak well of her and feel that she is approachable, professional and handles management issues well. Minutes of staff meetings were requested but not received by the CSCI. It Asher House DS0000066638.V345300.R01.S.doc Version 5.2 Page 22 is therefore not possible to see how often she meets with her staff and the subjects they discuss. An externally purchased audit system is in place that was last completed in August 2006. This was reviewed and appears very complex and completed as a paper exercise, with no results or action plans in place. This use and value of this system should be reviewed. There are no indications that the home uses any other systems to obtain feedback from residents, relatives and visiting professionals. The manager does not mention the development of a quality assurance programme under the management section in her annual quality assurance assessment. The deputy manager was unsure as to the use of this system. Senior staff should be aware of the quality assurance systems in the home. The home uses purchased polices and procedures, which have the name of the home put on. The manager needs to ensure that these are kept up to date as many of them are dated 2004. The manager does hold some monies on behalf of residents. This was checked at random and found to be in order with receipts available. It is recommended, as part of the quality assurance system, that a double signature audit system is introduced. A health and safety policy is in place. Accident records were checked and detailed records are maintained and there is evidence of follow up. Where appropriate the team at the home have linked in with the falls prevention team and complete a falls register. The deputy manager was unable to locate the risk assessments for the home and these were requested to be sent on but were not received by the CSCI. Asher House DS0000066638.V345300.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 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Asher House DS0000066638.V345300.R01.S.doc Version 5.2 Page 24 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. 1 Standard OP7 Regulation 12 and 15 Requirement Residents must have an up to date care plan in place that outlines their current needs. This must be kept under review and where possible involves them or their relative in the process. Where risk assessments are completed for residents these must outline the current risk and subsequent management and be kept under regular review. Residents care plans must reflect their individual preferences and choices regarding their care and be more person centred to evidence that staff appreciate the diversity of individual residents. Through assessment and consultation, the team at the home must ensure that residents’ individual social care needs are met and that their independence and self worth is promoted. The complaints procedure needs to be accessible to all residents and visitors to the home and evidence should be available to DS0000066638.V345300.R01.S.doc Timescale for action 14/09/07 2 OP8 12 and 13 14/09/07 3 OP10 12 14/09/07 4 OP12 16 14/09/07 5 OP16 22 31/08/07 Asher House Version 5.2 Page 25 6 OP18 13 7 OP19 23 8 OP19 23 9 OP29 18 10 OP33 24 11 OP38 13 show that concerns and complaints have been dealt with appropriately. Staff must be able to demonstrate a good understanding of adult protection procedures in order to ensure that issues are dealt with appropriately. The home must be kept in good decorative order with regard to downstairs hall carpets and bathrooms. The home must be maintained in a safe condition and have an up to date certificate for the wiring of the home and all gas appliances. All staff working at the home must have the appropriate police/personal checks in place to help ensure resident safety. A robust quality assurance system must be in place that obtains feedback from residents, relatives and visiting professionals and is backed up by an internal audit system. A risk assessment must be carried out in relation to the provision of window restrictors on upstairs windows and the appropriate action taken. 31/08/07 31/10/07 31/08/07 31/08/07 30/09/07 31/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP1 Good Practice Recommendations The service user guide should be reviewed so it is more user friendly for residents in relation to format, print size etc. DS0000066638.V345300.R01.S.doc Version 5.2 Page 26 Asher House 2 3 4 5 6 7 8 OP14 OP19 OP26 OP30 OP35 OP37 OP38 Residents’ choices regarding daily routine and the provision of care should be evident in the care plan. The fire safety risk assessment should be reviewed regularly and fire alarm tests checked consistently. A copy of the local infection control teams guidance should be available in the home. All staff must have up to date fire safety training. A double signature audit system should be in place to check that residents’ monies are being managed correctly. Policies and procedures must be kept under review and up to date. Risk assessments for the home and safe working practices should be completed and kept under review. Asher House DS0000066638.V345300.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Asher House DS0000066638.V345300.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. 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