Inspection on 10/05/07 for Ashgate House Nursing and Residential Home

This inspection was carried out on 10th May 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ashgate House Nursing and... 05/09/06

Ashgate House Nursing and... 19/04/06

Ashgate House Nursing and... 22/01/06

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

CARE HOMES FOR OLDER PEOPLE Ashgate House Nursing and Residential Home Ashgate Road Chesterfield Derbyshire S427JE Lead Inspector Bridgette Hill Unannounced Inspection 10th May 2007 09:20 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 Ashgate House Nursing and Residential Home DS0000066966.V336534.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. Ashgate House Nursing and Residential Home DS0000066966.V336534.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashgate House Nursing and Residential Home Address Ashgate Road Chesterfield Derbyshire S427JE 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) 01246 566958 01246 566216 Ashgate Care Limited Vacant Care Home 34 Category(ies) of Dementia (29), Dementia - over 65 years of age registration, with number (29), Mental disorder, excluding learning of places disability or dementia (5), Old age, not falling within any other category (29) Ashgate House Nursing and Residential Home DS0000066966.V336534.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registration of the MD category is to Room 18 - Single Room, Room 19 - Double Room, Room 20 - Double Room. A total of 5 places. 5th September 2006 Date of last inspection Brief Description of the Service: Ashgate House is situated on the western outskirts of Chesterfield, within the area of Ashgate, Chesterfield. It is a large converted building, rather than purpose built. The bedrooms are of various sizes and situated on the ground and first floor. The lounges and dining room are located on the ground floor. The company applied for and was granted a variation in the registration. The home now provides accommodation for 29 older people with Dementia and has accommodation for 5 older people with Mental Disorder and is registered to provide personal and nursing care. The fees charged at the home range from £343.20- £489.50 per week extra charges apply for chiropody, hairdressing, toiletries, personal newspapers, specialised laundry and outings. The inspection report from the last Commission for Social Care Inspection visit was available on request from the office but not openly available although a range of information published by the Commission for Social Care Inspection was located in the reception area. Ashgate House Nursing and Residential Home DS0000066966.V336534.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit which focused on assessing compliance to previously listed requirements and on assessing all key standards. As part of the inspection a sample of service users care files and a range of documents were examined. A tour of the building was conducted. During the visit opportunity was taken to have discussions with management, staff and service users. As the home cares mainly for service users with Dementia many service users were unable to convey their opinions of the home. The person in charge at this visit Initially Barbara White. The Acting Manager Jane Ridge arrived later during the day. What the service does well: What has improved since the last inspection? What they could do better: There is scope to improve the range of information regarding the home and ensure that all service users have Terms and conditions of residency contracts and are familiar with the content of these. Ashgate House Nursing and Residential Home DS0000066966.V336534.R01.S.doc Version 5.2 Page 6 The recruitment procedure whilst largely meeting standards is not robust in securing references from the most recent employers and ensuring that references are from acceptable sources. There has been a number of staff recruited in the past few months and these staff are working with only a pova first check being in place whilst full Criminal Records Bureau checks are being processed. These staff are not recorded as working in a supervised capacity and are part of the required compliment of staff. The quality assurance processes in place are not ensuring that there is action taken to Commission for Social Care Inspection requirement and that the service is one which is improving and monitoring quality. 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. Ashgate House Nursing and Residential Home DS0000066966.V336534.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 Ashgate House Nursing and Residential Home DS0000066966.V336534.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): 3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are assessment s completed of service users needs prior to admission to ensure the home can meet needs. More information would be preferred by service users to ensure they can make informed decisions. EVIDENCE: The file of a recently admitted service user was examined. Pre admission paperwork was evident and a visit by the Acting Manager had completed and an assessment recorded. In this file and other files seen assessments from Social services or Free Nursing care Assessors were available. Whilst not formally assessed during the visit questionnaires received indicated that a number of service users had not received Terms and conditions of residency contracts and more information on the service would have been Ashgate House Nursing and Residential Home DS0000066966.V336534.R01.S.doc Version 5.2 Page 9 preferred prior to admission. One questionnaire indicated that the new Manager was addressing this. The home does not offer intermediate care as defined by National Minimum Standards 6. Ashgate House Nursing and Residential Home DS0000066966.V336534.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 good. This judgement has been made using available evidence including a visit to this service. There were care plans in plans which were sufficiently detailed and personalised to ensure that staff would be aware of service users needs. EVIDENCE: A sample of three service users care files were examined to assess how standards were being met. Some were assessed in part to explore different aspects. The care plans in place were found to be well detailed and descriptive of the service users as individuals. There were comprehensive care instructions given particularly for problems such as Diabetes. Individual preferences and routines were included as part of the care plans. The care needs also considered the service users strengths and abilities and detailed what the service users could do for themselves therefore promoting independence. Ashgate House Nursing and Residential Home DS0000066966.V336534.R01.S.doc Version 5.2 Page 11 Care plans had been reviewed on a monthly basis. No care plans were seen where service users had been involved in the care planning process, this is largely due to many service users not having the capacity to do so due to dementia. Some information on medial conditions which had been sourced from the internet as placed within care files to give staff further information. Multi agency reviews were evident where relatives had been involved. A range of risk assessments were in place including for tissue viability and nutrition. These had been reviewed monthly and where changes had taken place this was recorded. The storage and administration of medicines was examined at his visit. Medication administration records were fully completed with signatures and totals of the amount of medications received in. Disposal records were retained and appropriate methods of disposal used. Visits by healthcare professionals were record. A private chiropodist visits the home regularly. Arrangements are in place for an optician and dentist to provide care to service users if they wish to choose these services. Service users were supported to attend outpatient clinics and letters seen were complimentary of the staff and their knowledge of the service users. Service users appeared to be clean and were well dressed. One relative stated they felt’ happy their parent was in safe hands’. The friendly attitude of staff was commented on by one relative. Ashgate House Nursing and Residential Home DS0000066966.V336534.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 excellent. This judgement has been made using available evidence including a visit to this service. There was a well planned and consistently offered range of activities in and out of the home to service users, this included activities aimed specifically at service users with dementia. EVIDENCE: An activities coordinator is in post who works 30 hours per week. A structure was in place to provide regular activities to service user. This included in house activities such as bingo, quizzes, crafts, manicures, nails. One specialist organisation which provided music to service users with dementia visited the home on a regular basis. Care plans were in place for social interests and individual interest found to be recorded. There were records for each service user of the activities they had become involved in there was evidence that interest were taken into account. For example a service user who liked gardening time was spent in the garden of the home talking about plants on a one to one basis. Ashgate House Nursing and Residential Home DS0000066966.V336534.R01.S.doc Version 5.2 Page 13 There were press cuttings at the home of a pantomime put on by staff which was said to have been enjoyed by service users and relatives. The next pantomime was being planned with service users helping to make props and scenery. A video and book library was being developed and films were included as part of the activities. Music played in the home during the visit was of a suitable genre for the service user group. A ‘Tuck shop’ had also been introduced in order hat service users could purchase their own toiletries and sweets and sundries. Easter, Valentines Day and Mothers day were celebrated with special meals such as ‘high tea’, Easter egg hunts and bonnet making. Photographs and press cuttings were evident on the walls to mark some of the events that had been organised. There was also a summer fayre being organised with local dignitaries and a celebrity being booked to attend and open the proceedings. One service user spoken to said they liked to get involved in anything that was happening. They also said they had been out of the home on trips. The lunchtime meal was observed. This was a choice of shepherds pie, chicken and mushroom pie, mashed potato and brussel sprouts. Service users were given a choice at the time the meal was served. The pudding served was not the one on the 4 weekly menu. This was said to be due to not having an ingredient in stock. Service users routines were included in care files. Service users spoken to said that some service users went to bed early but they liked to at 10.00pm. Service users said the meal was ‘very nice’. Some service users required help to eat and staff sat with service users to assist them. Staff wore aprons to serve meals. Other aids such as plate guards were seen being used by service users. Ashgate House Nursing and Residential Home DS0000066966.V336534.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 adequate. This judgement has been made using available evidence including a visit to this service. There are systems in place to ensure that any concerns by service users are recorded and handled appropriately. Some staff have not received Protection of vulnerable adults training and there is poor recording of Protection of vulnerable adults concerns. There is the therefore potential for allegations and concerns not to be handled appropriately and service user to be placed at risk. EVIDENCE: The pre inspection questionnaire received by Commission for Social Care Inspection recorded that no complaints had been received at the home in the past 12 months. The Commission for Social Care Inspection had received no complaints since the last inspection on 5.9.06. A copy of the complaints procedure was on display in the reception area. Service users spoke to said they would talk to staff if they had worries and were able to name staff they would go to. A new form was available to record any concerns that were raised. The Pre Inspection Questionnaire indicated that there had not been any investigations relating to safeguarding adult concerns in the past twelve months. There have actual been some investigations held regarding care in the Ashgate House Nursing and Residential Home DS0000066966.V336534.R01.S.doc Version 5.2 Page 15 past year which have not been substantiated. The Acting Manager who completed the form said that it had been difficult to find accurate information to complete the form. Some adult protection training had taken place for staff since the last visit. There were staff working however who had commenced in post in the past month who had not received training and no dates had been planned to complete this. One staff member had completed a trainers course in the Protection of vulnerable adults. The Protection of vulnerable adults procedure in place was not specific to the home and advocated investigation by the homes staff prior to the instruction to utilise locally agreed procedures. A copy of the locally agreed procedures was available. Ashgate House Nursing and Residential Home DS0000066966.V336534.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): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There has been continuous upgrading and investment in the environment to ensure that service users are cared for in comfortable, clean surroundings. EVIDENCE: A partial tour of the home was made, this included the communal areas and some bedrooms. The home has two lounge areas and two dining rooms although one is not currently being used. The home is converted from a previously grand domestic premise and a number of original feature have been retained such as coving panels and fireplaces. There has been recent upgrading of some parts of the environment and this is ongoing this has included bathrooms being retiled and new flooring fitted. Some bedrooms were also being refurbished with new flooring wash Ashgate House Nursing and Residential Home DS0000066966.V336534.R01.S.doc Version 5.2 Page 17 hand basins and furniture. One bathroom in the process of being refurbished had a clear glass window and no curtain/blind this had the potential for service users dignity to be compromised. The reception area had also been opened out and refurbished providing a more welcoming environment than previous. The home is set in rural surroundings and an enclosed secure garden area is accessible from one of the dining rooms. This had seating and umbrellas for service users to use. One review that had been held with relatives present recorded positively that progress was being made in upgrading the environment. This view was also expressed on some questionnaires completed by relatives prior to the inspection. The questionnaires also stated that relatives regarded the home as being clean. Bedrooms had the names of service users on them alongside a picture which held some relevance to the service user. Toilets and bathrooms were identified with signs for aid of recognition. The home was generally found to be clean as was reported on the questionnaires received from service users and relatives. Ashgate House Nursing and Residential Home DS0000066966.V336534.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some progress was being made on providing structured induction and training to staff to ensure that service users needs were being met. Recruitment procedures were largely implemented although the acceptance of references from unsuitable sources may place service users at risk. EVIDENCE: The occupancy of the home on the day of the visit was 21 service users. 20 service users required nursing care, 1 service user required personal care only. The typical staffing levels at the home were 1 nurse on duty for all shifts with 4 care staff for morning shifts, 4 care staff in the afternoons. At nights there was one qualified nurse and 2 care staff. There have been occasions when Agency staff have been used to cover absences that in house staff have been unable to cover. Ashgate House Nursing and Residential Home DS0000066966.V336534.R01.S.doc Version 5.2 Page 19 Additional kitchen and domestic staff were employed. A handyman was also employed on a full time basis who undertook general maintenance tasks, routine checks and decorating. From discussions with the Acting Manager and examination of training certificates there were 12 care staff employed at the home of which 4 held NVQ (National Vocational Qualification) level 2 in care qualifications. Discussions with the Acting Manager confirmed that one staff member had nearly completed the course and 3 were working towards it.. The Pre Inspection Questionnaire received indicated that there had been a high staff turnover of 22 staff within the last year. Recent rota’s examined that a number of staff were relatively new to post having started within the last two months. Some staff were working with full Criminal Records Bureau checks having been received. Pova first checks had been completed and were on file. These staff were included as part of the required numbers and it was not clear if they being fully supervised as is required when staff have not got full acceptable Criminal Records Bureau checks in place. A sample of staff personnel files were examined. Whilst two references had been obtained in all the files examined only one contained a references from the most recent employer. Some references had been accepted from unsuitable sources such as family relatives. It was also not always known or recorded in what capacity the applicant knew the referee. The files seen contained application forms, health questionnaires, proofs of identity and photographs. Some work had been done on the recording of training records with certificates. All staff had received moving and handling training including new staff who received training before working with service users. The range of training completed included moving and handling, fire safety, first aid, health and safety, continence, prevention of violence and aggression, Basic Food Hygiene, dementia care and tissue viability. Not all staff had completed every course listed. Some nurses had competed courses or were competent in tissue viability, venepuncture, and male catheterisation. Service users said of staff that ‘you could talk to them’ and they were ‘aright’. The questionnaires received back regarded staff as ‘approachable’ they were said to be responsive and listened to service users. Ashgate House Nursing and Residential Home DS0000066966.V336534.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,34,35,36,37,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are weak quality assurance processes in place which does not ensure that service users are receiving an improving service. There is little formal supervision of staff which may adversely impact on the care delivered to service users. EVIDENCE: An Acting Manager is in post who has commenced since the last inspection of the home. The Acting Manager has previous experience of home management. An application for the Manager to formally register with the Commission for Social Care Inspection and an interview date has been set. Ashgate House Nursing and Residential Home DS0000066966.V336534.R01.S.doc Version 5.2 Page 21 There have been a number changes in the Management of the home in the past year which appears to have affected the running of the home in particular implementation of supervision and quality assurance processes. Positive comments have been received on pre inspection questionnaires and seen documented in service users reviews regarding the new manager. The Provider is completing monthly visit reports at the home and some service user and staff comments are included. There are however no other strategies or systems in place to monitor and improve the service being offered. There are some unmet requirements from previous visits listed within this report. Some staff meetings have been held but minutes of these were not available as they were in the Acting Managers brief case. The Acting Manager said that there were some plans to introduce service user/relative and visiting professional questionnaires. A valid public liability certificate was on display. Records for establishing financial liability were not requested at this visit. Small amounts of service users monies were stored safely on behalf of service users. These were stored individually and securely. Records were kept which were doubly signed by two staff. Audits to check balances and records had been recorded on 1-3 monthly basis. Receipts for purchases typically chiropody and hairdressing were retained. Some purchases were made from the homes ‘Tuck shop’ which sold toiletries and sweets. One accounting error was evident during the checks and initially a discrepancy in the amount of money available and the actual amount recorded. An audit was completed and the money had been taken from an adjacent envelope so this was corrected during the visit. Some monies are held within the Providers account. This was said to be in the process of being resolved and returned to Social services for safekeeping. This has however been outstanding since the last inspection. Some valuables were stored safely but no system was in place to record what was stored or check that remained in storage. The majority of staff were not receiving any documented formal supervision. Only a few records were available to evidence any staff had had supervision. Some of these documented only observation of staff. The office where service users records were stored on open shelving was observed to be left open by staff when it was not occupied. This had the potential for service users records to be inappropriately accessed and confidentiality breached. Ashgate House Nursing and Residential Home DS0000066966.V336534.R01.S.doc Version 5.2 Page 22 A range of new policies and procedures have been implemented these are however not always representative of how the home operates. The servicing and maintenance of equipment in the home appeared to be in date although the date of the five-year electrical system could not be located. Accidents were reported and recorded. These included what actins had been taken. A number of accidents had been reported regarding limbs being trapped in bed rails. Reviews were reportedly then held regarding the use of these. Ashgate House Nursing and Residential Home DS0000066966.V336534.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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 x 2 x x x x 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 3 3 2 2 3 Ashgate House Nursing and Residential Home DS0000066966.V336534.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 OP2 Regulation 5 Requirement Service users must be provided with adequate information regarding the home which includes a Terms and conditions of residency contract in order that they can make informed choices The registered person must ensure that all staff receive training on Adult Protection. Previous timescales 19/06/06 3 OP21 12 Measures must be put in place to screen the clear glass bathroom window to sufficiently ensure service users dignity and privacy is maintained The Provider must ensure that at least 50 of staff hold NVQ (National Vocational Qualification) level 2 in care qualifications Previous timescale 30/10/06 30/06/07 Timescale for action 31/07/07 2 OP18 18 30/09/07 4 OP28 19 30/10/07 5 OP29 19 References for employees must DS0000066966.V336534.R01.S.doc 30/06/07 Page 25 Ashgate House Nursing and Residential Home Version 5.2 be from acceptable sources and include the employees most recent employer or records to indicate why this is not possible 6 OP31 8 The registered person must ensure that a registered manager is in post. Application has been submitted and an interview date has been set Previous timescale 19/10/06 7 OP33 24 The registered person must ensure that a quality assurance system with a systematic cycle is in place and being operated. This must include documented monthly visits made on the Providers behalf Previous timescales 19/07/06 & 30/10/06 8 OP36 18 (2) All staff must receive regular supervision. Previous timescales 30/06/06, 30/08/06 & 30/11/06 9 OP37 17(1)(b) Service users personal records must be held securely at al times to ensure service users confidentiality is protected 30/06/07 30/07/07 30/10/07 31/05/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ashgate House Nursing and Residential Home DS0000066966.V336534.R01.S.doc Version 5.2 Page 26 1 2 OP33 OP35 Policies and procedures in place should be reflective of the actual practices within the home Confirmation should be given that service users monies are not being held in the Providers bank accounts A system should be implemented to record where valuables are being stored safely on service users behalf Ashgate House Nursing and Residential Home DS0000066966.V336534.R01.S.doc Version 5.2 Page 27 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 Ashgate House Nursing and Residential Home DS0000066966.V336534.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. 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!