Inspection on 30/04/07 for Ashleigh House [Taunton]

This inspection was carried out on 30th April 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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashleigh House [Taunton] 17/01/06

Ashleigh House [Taunton] 15/09/05

Ashleigh House [Taunton] 10/12/04

Ashleigh House [Taunton] 20/07/04

Ashleigh House [Taunton] 11/03/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 Ashleigh House 20 Chip Lane Taunton Somerset TA1 1BZ Lead Inspector John Hurley Unannounced Inspection 30th April 2007 09:30 Ashleigh House DS0000059617.V336041.R01.S.doc Version 5.2 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 Ashleigh House DS0000059617.V336041.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 Adults 18-65. 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. Ashleigh House DS0000059617.V336041.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashleigh House Address 20 Chip Lane Taunton Somerset TA1 1BZ 01823 350813 01823 257914 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) Voyage Ltd No current registered manager Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places Ashleigh House DS0000059617.V336041.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16 September 2006 Brief Description of the Service: Ashleigh House is registered as a care home to provide personal care (PC) to eight people with a Learning Disability (LD) and Physical Disability (PD). The home is located within walking distance of Taunton town centre. Ashleigh House has eight single bedrooms and all bedrooms have full en-suite facilities. Two bedrooms are located on the ground floor. There is a large lounge, conservatory, dining room and kitchen. The home has a passenger lift to the first floor. The home is furnished and decorated to a very high standard. The current scale of charges for the home is £951 - £1,529 per week. Ashleigh House DS0000059617.V336041.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced key inspection of Ashleigh house of 2007. The inspection process followed the Commission for Social Care Inspection Inspecting for Better Lives methodology. Prior to the inspection the homes deputy manager completed a pre inspection questionnaire. The inspection at the service took 6 hours. The views of the service users and people important to them were also sought; where appropriate their comments are included in this report. The inspector toured the building, spoke with the visiting area manager, designated home manager, staff on duty and observed people who use the service go about their daily routines. They inspected a sample of the service users documentation along with records relating to staff and other documents required by regulation. The inspection took 6 hours to complete. What the service does well: What has improved since the last inspection? The service has introduced a pictorial menu which was recommended at the last inspection. Ashleigh House DS0000059617.V336041.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ashleigh House DS0000059617.V336041.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashleigh House DS0000059617.V336041.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. If followed the stated policies and procedures relating to new admissions will meet the requirements of the National Minimum Standards. EVIDENCE: The designated manager of the home informed the inspector that no new people had taken up residency since the last inspection. They further informed the inspector that should a prospective person wish to consider taking up residency they would provide information in the form of a service user guide and statement of purpose. This would also be complemented by visits to the home and meeting the existing people who use the service. They further informed the inspector that they would adopt a multi agency approach with regards to any new placements and use the local authorities single assessment process, if publicly funded, as a start point for establishing the individuals needs and whether the home could meet these needs or not. The care plans that were observed had been generated from the initial assessment also have a detailed service users guide, which is produced using pictorial images for greater access Ashleigh House DS0000059617.V336041.R01.S.doc Version 5.2 Page 9 Through information received via feedback from people important to those who live at the service them the inspector established that there were high levels of satisfaction with regard to the pre admission arrangements made by the home. The inspector considers that if the stated policies and procedures with regards to admission are followed then the service will met the National Minimum Standards required. Ashleigh House DS0000059617.V336041.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Individual aspirations and needs are well supported. Appropriate assessments are completed to ensure that the home will be able to meet individuals needs. Strategies for dealing with behaviour that challenges is not robust and may put individuals and staff at risk. EVIDENCE: Care plans included a photograph of the service user and provide information regarding service users needs, daily routines and preferences. The care plans also include records of visits to health care professionals, contact with families, activities undertaken and any accidents and incidents reported. There is evidence in the care plans of regular reviews with service users and family input. Systems are in place to monitor development and changes. This Ashleigh House DS0000059617.V336041.R01.S.doc Version 5.2 Page 11 combined with regular communications ensures that the service users initial and ongoing needs are met. Some risk assessments were seen in relation to individual’s behaviours, such as pinching or slapping. Through case tracking one individual who displays this type of behaviour it is apparent that this behaviour is acknowledged, what is less clear is how to deal with it. A number of risk assessments were further sampled and it was found that although they highlight risks they do not necessarily identify what measures have been put into place to minimise the risk. It would further improve the care needs assessments and associated plans if all individuals had a nutritional assessment which identified eating irregularities that impact on the wellbeing of the person. People who use the service are encouraged to exercise choice. This is done through individual communication system. There is a photo board displaying a staff photo indicating who is working that day. There is also a board displayed in the dining room displaying pictorial signs, photography and symbols listing the activities planned for that day. One individual uses a communication board. This person continues to use a communication passport, which enables the person to tell staff what they want to do or talk about. Some service users have a communication system in their bedroom to help them make choices in their daily lives. One example is a communication board to support a service user to make choice of what colour to wear on that day. The home keeps individual day to day records that detail the activities and choices that have been made by service users. Ashleigh House DS0000059617.V336041.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Opportunities for personal development are only limited through the individuals ability. People who use the service are given opportunities to develop personally and to take part in age appropriate leisure activities. Risk assessments are not available for people who undertake activities, which may place either themselves or staff members at risk of injury or harm. EVIDENCE: The inspector sampled the records of the home and observed the interactions between the staff and people who use the service as they went about their individual routines. A sample of the records observed demonstrated that the people engage in a Ashleigh House DS0000059617.V336041.R01.S.doc Version 5.2 Page 13 variety of age appropriate leisure activities with their peer groups. These included walks, swimming, music therapy, hydrotherapy, horse riding, massage, trampolining, reflexology, bowling, shopping and cinema. Some residents attended a local college. The feedback from relatives showed satisfaction with the services on offer and confirmed that they are consulted as appropriate. The service was not able to evidence that robust risk assessments are in place with regards to the activities individuals under take, which may impact on the safety of those who use the service. The inspector observed that there were enough food stocks of both fresh and other foods to provide the basis for a nutritious meal. Staff informed the inspector that they were aware of the individuals likes and dislikes and provided that the choices made by the individual ensured a degree of a balanced diet their wishes would be met. The home has a four weekly menu. The menus appear to provide a variety of foods that are nutritious and appetising. The staff team offer people choices in all aspects of food and drink and are very aware of the likes and dislikes of the service users. The Inspector briefly observed the lunchtime routine and noted that the mealtime was relaxed and unhurried. The home has a very pleasant dining room that appears very comfortable to eat in. The fridge and freezer were in good working order and daily temperature recorded. Cleaning schedules were seen and food probe temperature records were seen. All of which were recorded within the correct range. Ashleigh House DS0000059617.V336041.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19.20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users are well supported and their health needs are met. The storage, administration and recording of medication is poor and may put people who use the service at risk of harm. EVIDENCE: The home has appropriate aids and equipment to support service users mobility. The health and safety checks for these equipments are maintained regularly. The records observed evidence that service users have regular health care checks from the GP and community nurse. They also see other professionals including a psychiatrist, psychologist and physiotherapist. The inspector viewed the relationship between the service users present at the time of the inspection as both empathetic and professional. It was also observed that staff use positive encouragement to gently assist the individual when making choices. Ashleigh House DS0000059617.V336041.R01.S.doc Version 5.2 Page 15 At present service users are not able to retain or administer their own medication. The reasons for this are documented in the individuals file. It was evident from the care plans through regular monitoring that any changes in the service users wellbeing or behaviour would be identified. The manager and staff team would then take pro-active steps to address and meet changing needs. The care plans that were sampled contained documentation of the visits made to health care professionals. These included visits to the GP, dentist, chiropodist, optician, speech and language therapist, physiotherapist and consultant psychiatrist. Records are kept of all visits and consultations. The home’s procedures for the management and administration of medication were examined at this inspection. Medicines were not stored appropriately with a number of out of date preparations in the medication cabinet. An individual who attends the service on a daily basis and resides at the home at weekends has their medication brought in daily. As the preparation had been decanted from the original dispensed bottle there was no way to say exactly what the contents were. As the preparation was in liquid form the exact amount was also hard to establish. Medication that had a use by date, ie 7 days after opening, did not have a date recorded as to when it was opened The administration records were also sampled. It was noted that not all variable doses were accurately recorded, some homely remedies did not have written permissions to administrate them from the general practitioners. There was little evidence to suggest that medication administered on an as required basis had any rationale for its administration or evaluation of use. Through discussion with the designated manager prior to the inspection of the medication practices it was clear that they had already identified the shortfalls above. They were further able to evidence the action that they were taking to re-establish the National Minimum Standards required. For these reasons it is considered that although the medication practices are poor there is sufficient evidence to suggest that an adequate standard will be established shortly. Ashleigh House DS0000059617.V336041.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home takes reasonable steps to ensure the safety of the people who use the service through its revised policies and guidelines. EVIDENCE: Some people who use the service, due to the nature of their disabilities, communicate via routes other than speech. Due to this reason it was not possible for the inspector to communicate effectively with these people. However through discussion with the staff, and through feedback from people important to them it is clear that service users were listened to. The inspector noted the staff interactions with people who use the service and found it to be empathetic, meaningful and professional. Staff continue to develop individual forms of communication and appeared to be able to understand individuals needs. Relatives of people who use the service confirm that they are confident that should concerns arise the organisation will deal with them promptly. Ashleigh House DS0000059617.V336041.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean safe and meets the needs of the service user group. The use of keypads in-between the individuals bedroom and their en suite needs to be evaluated to ensure that this does not deny free access EVIDENCE: At the time of the inspection the home was found to be clean and comfortable. The service users rooms are personalised to reflect their individual tastes and preferences. The home has bedrooms on the ground and upper floors. The ground floor is fully accessible to those who require the assistance of a wheelchair. Additional ramps and lifts have been installed to allow a good degree of accessibility to lower floor activity areas. Ashleigh House DS0000059617.V336041.R01.S.doc Version 5.2 Page 18 The inspector was escorted on a tour of the premises. Ashleigh House is a large late Georgian house with large sized rooms. These comprise of a spacious lounge with lean to style conservatory. The conservatory provides additional communal space and is also used as a sensory room. Leading from the main hallway is a dining room. The dining room was clean and functional and also has a wash sink in the corner. The communal areas are domestic in nature providing comfortable seating and dining facilities The kitchen enjoys up to date kitchen units and has a small dining table and few chairs. This offers alternative dining area or space for cookery sessions. The kitchen was considered clean and hygienic. Near the kitchen is a goodsized laundry room, which houses an industrial washing machine and a tumble drier. It was found to be clean but not very well organised. Next to the laundry room is a small utility area, which provides an area for the storage for medication. The utility area was well lit and contained a small hand-washing sink. To the side of the house, there is a large private garden that is well maintained and not overlooked. The outdoor space is plentiful for outdoor games. The inspector viewed a number of the bedrooms. Each persons bedroom was specifically decorated to their taste and interest. The bedrooms were filled with a range of décor such as fairy lights, large framed photograph, comfortable armchair, television, DVD player, and personal memorabilia. The bedrooms are complemented by full en-suite facilities, which were also personalised in a bright and cheerful manner. It was noted that all rooms are assessed via a key pad locked door system. Due to some of the behaviours displayed by the occupants of the rooms some of the water taps in the en suite areas do not have a means to easily switch them on as the individual may flood the area. In at least one room the en suite and door to the room was only assessable through a key pad entry system. There was no rationale as to why both doors are required to be locked. Ashleigh House also provides service users with specialist equipment to meet the assessed needs of the individual. There are adapted beds, communication aids, specialist cutlery and tableware. Ashleigh House DS0000059617.V336041.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Staff are provided with appropriate training to undertake their role. There are sufficient staff on duty to meet service users’ needs. Staff are provided with regular supervision. There was insufficient evidence to say that the organisational policies are robustly followed, which may impact on the safety of those who use the service. EVIDENCE: The inspector asked staff about their job description and roles. They were reasonably clear as to what this entailed. New staff confirmed that they have undergone a thorough recruitment and selection process by way of a formal interview and statutory checks to establish their suitability to work in the home. The inspector was not able to verify if the new staff member’s had Ashleigh House DS0000059617.V336041.R01.S.doc Version 5.2 Page 20 under gone all statutory checks as significant information such as references were currently being held at the organisations head office. It is the organisations policy to ensure essential checks such as Protection of Vulnerable Adult (POVA1st), Criminal Records Bureau (CRB) and identification are done centrally and evidence is included in the file of a new staff member. The records that were sampled in relation to new staff members did not contain a full employment history, who had supplied references and in one case the Criminal Records Bureau number had not been entered. All of these issues undermine the integrity of the organisations vetting procedure and so may put people at risk. All new staff receive a comprehensive induction when they start at the home, one staff member has responsibility for supporting each of them through this process. All elements of the induction process are signed by both parties to confirm the element has been completed and understood. The records sampled confirmed that all staff receive the induction training In addition to this new staff complete the mandatory training required by the regulations. This induction process is good as it ensures that new staff have the basic skills required to start supporting people at the service. Following on from the induction staff train in areas such as food hygiene, first aid, health and safety, manual handling, protection of vulnerable adults and non-violent crisis intervention. The rotas viewed indicate that there is sufficient staff on duty to meet the individuals needs. The service provides a good ratio of staff to individual in line with their access needs. The inspector viewed the records in relation to staff supervisions and appraisals. The manager has an overview of all staff supervisions that have been conducted. Senior staff also provides supervision in order to maintain good frequency. Staff stated that they enjoyed working at the home and received appropriate support. Ashleigh House DS0000059617.V336041.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The new management arrangements should improve the shortfalls in meeting the National Minimum Standards so that people who use the service receive care in a consistent and planned manner. EVIDENCE: There had been a number of changes in the management of the home since the last inspection. At the time of the visit the newly appointed manager had only been in post for one week. Thorough discussion with them it is clear that they had highlighted similar problems as identified in this report and were able to evidence that they had an action plan in dealing with them. At the time of writing this report a formal application to become the registered manager of the service has yet to be received by the Commission for Social Care Inspection. Ashleigh House DS0000059617.V336041.R01.S.doc Version 5.2 Page 22 The feedback for some of the relatives identified some concerns with regards to the changing management and new staff members at the home. They commented that they felt it would be helpful if they were introduced to new members of staff where at all possible and also to know something of their professional background. One relative considered that the number of staff changes had impacted negatively on the care needs of their relative in so much as there was not the continuity of care which is required in dealing with some very complex needs and communication systems. Staff at the home seek peoples views on an individual basis, taking account of behaviours, verbal and non-verbal communication. There is a person centred focus which was evidenced through the examination of care records and observations of staff interactions with people who use the service . The feedback also contained supportive comments in relation to the services ability to sit down and discuss issues with them and to sort problems out. The home operates a comprehensive system of health and safety audits. Fire safety records were examined. Fire equipment had been serviced and tested as required. The electrical hardwiring certificate, portable appliances and landlord gas safety certificates have been appropriately maintained. Ashleigh House DS0000059617.V336041.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 Adults 18-65 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 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 2 27 2 28 3 29 3 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 x 3 x 3 x x x 3 Ashleigh House DS0000059617.V336041.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? 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 YA20 Regulation 13(2) Requirement The responsible individual must make arrangements to ensure that there are robust systems in place to ensure that • All medication is dated when opened and discarded by the use by date • That medication is administered from the original container it is dispensed in • That all medication is recorded as being accepted into the service, recorded when administered and any returns further recorded. These measures will ensure that the practice of giving medication to the people who use the service is safe. The responsible individual must ensure that employment checks are robustly completed and sufficient evidence is available for inspection so as to demonstrate how the service protects the individuals who use DS0000059617.V336041.R01.S.doc Timescale for action 04/06/07 2 YA34 19 04/06/07 Ashleigh House Version 5.2 Page 25 the service. 3 YA9 13(4) The responsible individual must 04/06/07 make arrangement to ensure that all challenging behaviour is routinely risk assessed and the action to be taken to avoid unnecessary harm to the individual and staff is recorded. The responsible individual must 04/06/07 make arrangement to ensure that all activities that people who use the service take part in are risk assessed to ensure the safety and suitability of those individuals The responsible individual must 04/06/07 make arrangements to ensure that the use of key pads within the home does not unnecessarily restrict the freedom of movement of the people who uses the service. 4 YA9 13(4) 5 YA26 13(4) 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 YA5 Good Practice Recommendations It is recommended that each individual has a written contract or statement of terms and conditions with the home and available locally. Ashleigh House DS0000059617.V336041.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Ashleigh House DS0000059617.V336041.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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