Inspection on 21/12/06 for Ashley House Care Home

This inspection was carried out on 21st December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ashley House Care Home 03/04/08

Ashley House Care Home 06/11/07

Ashley House Care Home 03/10/05

Ashley House Care Home 19/10/04

Ashley House Care Home 20/04/04

Similar services:

Trevayler Residential Care Home

Thornham Grove

Thistle Hill Hall

Conifer Lodge

Westwood Lodge

Egerton Lodge Care Home

Alfred Minto House Care Home

St Matthews Unit

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

CARE HOMES FOR OLDER PEOPLE Ashley House Care Home Sunnyside Worksop Nottinghamshire S81 7LN Lead Inspector Dawn Podmore Key Unannounced Inspection 21st December 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ashley House Care Home DS0000024625.V324257.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. Ashley House Care Home DS0000024625.V324257.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashley House Care Home Address Sunnyside Worksop Nottinghamshire S81 7LN 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) 01909 500541 01909 500542 Mr L M Patil Vacant Care Home 40 Category(ies) of Dementia - over 65 years of age (40), Mental registration, with number disorder, excluding learning disability or of places dementia (10), Mental Disorder, excluding learning disability or dementia - over 65 years of age (40) Ashley House Care Home DS0000024625.V324257.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The 10 Places in category MD are available for people of 50 years of age and above 3rd October 2005 Date of last inspection Brief Description of the Service: Ashley House is located on the outskirts of Worksop. A car park is available at the side of the home and it is on the bus route into the town. The home provides nursing and personal care for 40 residents, including older people with special mental health needs. Within this number the registration allows admission for up to 10 service users over 50 years of age. The home is privately owed by Mr Patil and was opened in 1988. It consists of a large converted old house, with a purpose built lounge and bedroom extension on the ground floor. Plans have recently been passed by the local council to allow the owner to upgrade the home and build a 32 bed extension. There are 17 single and 9 double bedrooms, 6 of the double rooms having ensuite facilities. The first floor is accessible by a lift. The homes grounds are well laid out and provide a secure environment for residents. At the time of the inspection the owner confirmed that the weekly fees ranged from £319 - £343 depending on the residents assessed needs. Additional charges are made for services such as chiropody, toiletries and hairdressing. Information about these costs as well as the day-to-day operation of the home, including a copy of the last inspection report, is available at the home. Ashley House Care Home DS0000024625.V324257.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took any previous information held by the Commission about the home into account. The inspection included a site visit, which took place over approximately six hours. The main method of inspection used was called case tracking. This involved selecting three residents and tracking the care they receive through the checking of records, discussion with them, the care staff, and observation of care practices. A partial tour of the premises was also conducted. Interviews with residents, relatives, and a visiting nurse took place and 3 relatives returned completed questionnaires to the Commission before the visit. The acting manager was not present on the day of the visit so the clinical manager and the owner assisted in the inspection. On the day of the visit 27 people were living at the home. What the service does well: What has improved since the last inspection? What they could do better: Although care plans, telling staff about the care people require, contained some good information they need to be improved so that they provide more detailed information for staff. Areas needing improvement include the detail of peoples care needs, especially those relating to medical conditions, risk assessment, and completion of forms. Monthly reviews of the planned care had been carried out but these did not contain enough detail to show whether or not there had been any changes in peoples needs. Ashley House Care Home DS0000024625.V324257.R01.S.doc Version 5.2 Page 6 Although the care staff had tried to meet residents’ social needs evidence available did not demonstrate that this had happened. The owner needs to make sure that care plans identify the type of stimulation individual residents prefer and provide a varied programme of activities that meets these needs. The home is partly staffed by adaptation nurses, who are recruited by an agency. Although a police check had been carried out in their country of origin one staff member who ad been at the home for some months did not have a Criminal Records Bureau certificate on file. Other staff had been recruited following the correct recruitment procedures. Mrs Patil is currently the acting manager at the home, but she has not been registered with the Commission. Anyone managing the home must be registered or have expressed their intent to register by submitting an application; otherwise an offence is being committed. The owner must decide who the manager is to be and ensure that they apply to the Commission. Some other areas needed some attention, these include: It is good practice for the person filling in the medication charts to sign and date any hand written additions. Documentation is available to record any complaints, the actions taken and the outcome but the content could be improved. Some areas of the home are in need of redecoration, this should be considered in the homes budget for 2007. Although financial transactions were accurately recorded they should be signed by 2 people to provide added security. 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. Ashley House Care Home DS0000024625.V324257.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 Ashley House Care Home DS0000024625.V324257.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. A satisfactory admission procedure ensures that prospective residents receive an assessment before admission to assure that the home is able to meet their needs. EVIDENCE: The home has an admission procedure, which includes assessing residents before admission. Records and peoples comments confirmed that adequate assessments had taken place and people had been invited to look round the home before moving in. The clinical manager confirmed that the home is currently not providing intermediate care. Ashley House Care Home DS0000024625.V324257.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8. 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Shortfalls in care planning and risk assessment documentation puts residents and staff at risk and could lead to residents care needs not being met. Residents’ health needs are being satisfactorily met. Medications are stored, administrated and disposed of safely. Staff respect the wishes and preferences of people living at the home while maintaining their privacy and dignity. EVIDENCE: Each resident has an individual plan, which contains information about his or her care needs. Although the plans seen contained good information there was no planned care for some highlighted needs. For example one assessment stated that the resident had diabetes but there was no instructions or guidance for staff on how to manage this need. Files did not contain detailed plans outlining how staff could meet resident’s social needs. The review of care needs for one resident clearly identified that a social programme needed to be developed as part of their support, but this had not been formulated. The clinical manager said that stimulation was being provided but records did not support this. Lists of activities undertaken by Ashley House Care Home DS0000024625.V324257.R01.S.doc Version 5.2 Page 10 individual people were contained in the files but these consisted of mainly family visits and music therapy. The home needs to identify resident’s individual preferences regarding social stimulation and provide a suitable programme to meet these needs. At the last inspection time was taken to discuss how this area could be improved but little or no action has been taken to meet the requirement made following that visit. Manual handling risk assessment had been completed but one did not identify that the resident used a frame to walk with; this was included elsewhere in the care file but could mislead staff. Assessments in one plan highlighted that the resident could be at risk in certain other areas but there was no detailed information to tell staff what measures had been put in place to minimise these risks. Risk assessment tools, such as for pressure risks, need to be kept up to date. For example one file contained assessments carried out in 2003; these had not been meaningfully evaluated or changed since that date. Records such as pressure and nutritional assessments had not always been signed or dated by the staff member completing them. This should be done to provide an accurate history of events. Details of the wishes of residents with regard to terminal illness and death were completed in the plans seen. Care plans had been reviewed monthly however they consisted only of a date and signature so did not give an evaluation of any improvements or deterioration in the resident’s condition, therefore did not evaluate the effectiveness of the planned care. Staff demonstrated a good understanding of people’s individual needs and preferences. They were seen speaking to them in a respectful, friendly manner. Residents and relatives said that they were happy with the standard of care provided. Comments included: ‘my brother says that he is happy living at the home and the family are happy with this’ and ‘the staff are very caring and do their best to make the patients comfortable’. Records showed that outside agencies such as, doctors, opticians and chiropodists had visited the home regularly to meet people’s health care needs. A visiting nurse said that she felt that residents were well cared for and their health care needs were being met. The home has satisfactory policies and procedures regarding the receipt, storage, administration and disposal of medications. Records showed that these were being followed with the exception of the record for one resident. Medications had been omitted due to illness but these had not been correctly coded on the administration form. It was also recommended that any handwritten additions to administration sheets should be signed and dated by the nurse completing the new entry. Ashley House Care Home DS0000024625.V324257.R01.S.doc Version 5.2 Page 11 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 adequate. This judgement has been made using available evidence including a visit to this service. Residents are happy with their lifestyle at the home but records do not adequately demonstrate that people’s social needs are being considered or adequately met. Residents maintain good contact with their families, friends and the local community. Residents’ are offered choice regarding their daily lives. Meals provided offer variety and choice. EVIDENCE: People said that since the activities coordinator left in the summer there has been no formal activities programme in place. The clinical manager said that care staff facilitated activities but care records did not support that this had happened. At present there is no planning of activities in line with assesed needs of residents. Residents spoke of playing games, such as pool, and relatives said that activities did take place, but these had been less evident recently. There were DVDs and videos available to entertain and stimulate residents and the clinical manager said that games such as magnetic darts were also available. Although there was no evidence available she also said that a Christmas carol concert had recently taken place, entertainers visited regularly Ashley House Care Home DS0000024625.V324257.R01.S.doc Version 5.2 Page 12 and a Christmas party was planned for December 25th with a festive lunch and presents. There are no restrictions on people receiving visitors unless at the request of the resident. Six relatives were spoken to on the day of the visit and 3 completed questionnaires. They commented that staff were always friendly and the atmosphere at the home was always welcoming. One relative confirmed that her relative went out into the community, with the support of an outside agency and the family. Residents said that they were offered choice in their daily lives such as menu options, times for getting up and going to bed. Bedrooms had been personalised and relatives confirmed that they had been encouraged to bring small items of furniture, photographs and mementoes to the home. People’s religious preferences were recorded in their care plan and entries in one plan, as well as comments made by his family, showed that the resident visited a local church regularly. Residents were seen eating their lunchtime meal in the dining room and the ground floor lounge area. The meal served was nutritionally balanced and well presented. Residents spoken with said that they enjoyed the food at the home but one said that his food was sometimes cold. Relatives said that they were happy with the menu options available for their relatives. Comments included: ‘ my brother says that he usually enjoys the meals’, ‘the meals I have seen look nice’ and ‘I am happy with the food’. One relative said that they thought that the menu for the day should be displayed so that residents were reminded of their options. For people unable to sit at a table staff assisted them to eat their meals in a lounge chair. Although staff behaved discreetly and respectfully some were standing while providing assistance. It was suggested that it would be more relaxing for residents if staff were seated so that they were on the same level as the person they were feeding and therefore could interact more effectively with them. Ashley House Care Home DS0000024625.V324257.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has satisfactory procedures for handling complaints and people felt confident that any concerns would be addressed appropriately. Residents are protected by the home’s procedures for handling allegations of adult abuse. EVIDENCE: The home has a complaints procedure, which tells residents and relatives how to make a complaint and how it will be handled. This is usually displayed in the main lounge but had been taken down while the room was being redecorated. Records showed that the home had received 2 complaints in the last year; both had been investigated but recording could be improved. Relatives and residents said that they knew how to make a complaint and felt that any concerns would be dealt with promptly. The 3 returned questionnaires indicated that people were happy with the overall service provided. On the day of the visit people said ‘we are very happy with the care provided’ and ‘we are happy to talk to the staff about any areas of concern’. There are satisfactory procedures in place relating to adult protection. Staff comments and records showed that most staff had received adult protection training. Ashley House Care Home DS0000024625.V324257.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the home live in a clean, comfortable and homely environment but some areas of the home are not well maintained. EVIDENCE: A partial tour of the building, which included some bedrooms, communal areas and toilets, showed that although some redecoration had taken place some areas of the home were looking tired and in need of redecoration. The proprietors are planning to extend the home and upgrade existing facilities, but no date has been set for the work to commence. Preinspection information provided by the owner said that 4 double rooms had been fitted with ensuite facilities and walk in showers since the last inspection. It also said that new carpets had been fitted in some bedrooms and hallways, and that the floors in the dining room and day room had been restored. Residents and relatives said that they were happy with the accommodation and the home’s general facilities. Ashley House Care Home DS0000024625.V324257.R01.S.doc Version 5.2 Page 15 A comment from a relative who completed a questionnaire said ‘sometimes when I call there is a smell of urine’ but on the day of the inspection the home was clean and odour free throughout. The same person also commented about the quality of returned laundry, but this issue was not raised by anyone else consulted. Ashley House Care Home DS0000024625.V324257.R01.S.doc Version 5.2 Page 16 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. Staff are on duty in sufficient numbers and skill mix to ensure that the residents are cared for in a safe, caring and competent manner. The home has a satisfactory procedure for recruiting staff but this had not always been followed, which could put people at risk. Staff receive training to meet the needs of people living at the home. EVIDENCE: Duty rotas and peoples comments demonstrated that the home was providing adequate staffing levels for the number of people currently living at the home. There is a nurse on duty 24 hours a day. Relatives said, ‘staff are helpful and friendly’ and ‘the staff seem to change a lot but they are all caring and lovely’. A nurse visiting the home said that staff were flexible and communicated well. She said that whenever she visited there always seemed to be lots of staff on duty with a minimum of 2 in the day room. Staff confirmed that there was enough staff on duty to meet residents needs. The home has a satisfactory recruitment procedure in place, which had been followed in respect to recruitment in this country. However the file of a recently employed overseas adaptation nurse showed that appropriate checks had not taken place. Information available included written references, proof of acceptance onto the overseas nurses programme from the Nursing and Midwifery Council and a police check from her country of origin, but no C.R.B. (Criminal Records Bureau) check. The owner said that one had been applied Ashley House Care Home DS0000024625.V324257.R01.S.doc Version 5.2 Page 17 for but due to the form being incorrectly completed it had been delayed. He could not supply any evidence that an application had been submitted and confirmed that he had not applied for a P.O.V.A. first check (Protection Of Vulnerable Adults). This check is carried out to ensure that the staff member is not on the register while they wait for the full C.R.B. check to be completed. Until a satisfactory C.R.B check is received the person must be fully supervised. At the last inspection this was highlighted and a requirement made for the home to do so in future. This has not been addressed. Staff comments and files demonstrated that new staff had received a comprehensive induction to the home when they started to make sure that they had all the essential information they needed to carry out their work. Records and staff comments confirmed that essential training had been provided, this included, adult protection, manual handling, challenging behaviour, dementia and basic food hygiene. All care staff are either qualified nurses or are enrolled on an N.V.Q. (National Vocational Qualification) course. This course helps to make sure that carers have the knowledge and skills to provide a good standard of care. Staff said that they felt well-supported and received regular supervision and support; records confirmed this. Ashley House Care Home DS0000024625.V324257.R01.S.doc Version 5.2 Page 18 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 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is no Registered Manager for the home to regularly and consistently oversee and lead staff. Sufficient guidance and direction is being provided to staff to ensure that residents receive a satisfactory standard of care. The home adequately consults people about the care they receive. Residents’ finances are handled appropriately. The home has health and safety policies and procedures, which help to safeguard staff and residents. EVIDENCE: The home does not have a Registered Manager and no application has been submitted to the Commission. Mr Patil said that his wife was the acting manager and a clinical manager, who was on duty on the day of the visit, had been appointed to manage the day-to-day running of the home. The owner needs to submit an application as soon as possible so that clear lines of accountability are established. Ashley House Care Home DS0000024625.V324257.R01.S.doc Version 5.2 Page 19 Residents, relatives and staff said that they were happy with the way the home was managed. People commented: ‘it’s a lovely home’ and ‘the management team are very friendly and approachable, and people are always treated with respect’. A visiting nurse said that she felt that the owners recognised the homes weaknesses and strengths and built on these to improve the service they provided. At the last visit the owner had not regularly asked people if they were happy with the way the home was run. Since then questionnaires have been used to gain residents views. The home has successfully attained the quality assurance award (ISO 9000) and carries out quality audits to ensure that standards continue to be met. Residents and relatives confirmed that they were happy with the services provided. The records for the person allowances of two residents were examined. These were adequately documented and included receipts. However some entries only had one signature therefore it was recommended that all transactions be signed by two people to verify that totals are correct and provide added security. There are a range of policies and procedures regarding health and safety available to guide and instruct staff. There is also a programme in place to service and maintain the equipment in the home on a regular basis. Information provided to the Commission and sampling on the day of the visit showed that appropriate checks on equipment such as hoists and the lift had taken place. Ashley House Care Home DS0000024625.V324257.R01.S.doc Version 5.2 Page 20 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 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Ashley House Care Home DS0000024625.V324257.R01.S.doc Version 5.2 Page 21 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 OP7 Regulation 15(1) 17 (1) (a) Requirement Timescale for action 01/03/07 2. OP7 13(4) (c) 3. OP9 13 (2) The Registered Person shall after consultation with the service user, or a reprehensive of his, prepare a written plan in respect of his health and welfare. Care plans must provide adequate detail and guidance to staff about all identified needs and include how peoples social needs will be met by the home. The registered Person shall 01/02/07 ensure that unnecessary risks to the health and safety of the service user are identified and so far as possible eliminated. Risk assessments must identify all potential risks accurately and provide staff with a detailed management strategy for each area of potential risk. 01/02/07 The Reponsible Person shall make arrangements for recording, handling, sfaekeeping, safe administration and disposal of mediciens received into the home. The reasons for any medications being omitted must be accurately recorded. DS0000024625.V324257.R01.S.doc Version 5.2 Ashley House Care Home Page 22 4. OP29 19 (10) The Responsible Person must apply for a Criminal Records certificate and receive a satisfactory P.O.V.A. check prior to all staff starting work at the home. 01/02/07 5. OP31 8 The registered provider shall 01/03/07 appoint an individual to manage the care home. The owner must ensure that the person appointed to manage the home submits an application to be registered with the Commission. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP9 OP16 OP35 Good Practice Recommendations All handwritten additions to medication records should be signed and dated by the person completing them. Documentation of complaints received at the home should be more comprehensive. Two signatures should be provided for each transaction made relating to residents finances, as this will make the current system more robust. Ashley House Care Home DS0000024625.V324257.R01.S.doc Version 5.2 Page 23 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 Ashley House Care Home DS0000024625.V324257.R01.S.doc Version 5.2 Page 24 - 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. 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