Inspection on 22/08/06 for Ashlyn

This inspection was carried out on 22nd August 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ashlyn 27/04/09

Ashlyn 02/05/08

Ashlyn 03/11/05

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

CARE HOMES FOR OLDER PEOPLE Ashlyn Vicarage Wood Harlow Essex CM20 3HO Lead Inspector Sharon Thomas Key Unannounced Inspection 22nd August 2006 09:30 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 Ashlyn DS0000062965.V309732.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. Ashlyn DS0000062965.V309732.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashlyn Address Vicarage Wood Harlow Essex CM20 3HO 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) 01279 868330 Ashlyn Healthcare Ltd Miss Carol Elizabeth Doherty Care Home 43 Category(ies) of Dementia - over 65 years of age (17), Old age, registration, with number not falling within any other category (43) of places Ashlyn DS0000062965.V309732.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 43 persons) Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 17 persons) The total number of service users accommodated in the home must not exceed 43 persons Service user bedrooms with an area of less than 10 sq.m. will be used only following a written assessment. The assessment should include consideration of whether the facilities in the room are suitable, and acceptable to, the service user, taking into account their mobility needs. The service user plan should reflect the assessment findings Date of last inspection Brief Description of the Service: Ashlyn is a care home owned by Excelcare Holdings PLC. It is located approximately 2 miles from the centre of Harlow but is within walking distance of shops, and local amenities. Ashlyn is a purpose built home that provides residential accommodation for 43 older people with low to high dependency needs, 17 of who have Dementia. The home provides personal care to those service users who have been assessed as needing this. The home aims to provide 24-hour individual care and is successful in meeting the physical, emotional and social needs of the service users who live there. The home has bedrooms located on both the ground and first floor; the upper floor of the house is accessible to all residents through the passenger shaft lift. The home is well decorated and offers a homely atmosphere to the individuals living there. The homes bed rates range between £437.71 and £478.59. Ashlyn DS0000062965.V309732.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on 22 August 2006, and took 5.5 hours to complete. Twenty-one of the thirty-eight National Minimum Standards were inspected: and all of these were met. For the purpose of this report the individuals living in the home spoken with on the day stated that they would prefer to be referred to as residents. The inspection process included: discussions with three residents, the manager, the deputy manager, three members of staff including the cook, and two relatives. The tour of the premises included observation of ten bedrooms, all of the bathrooms and toilets, the communal areas and the laundry. There was an opportunity to spend a considerable period of time observing the care being provided by the staff. The inspection covered the examination of a sample of policies and records (including any records of notifications or complaints sent to the CSCI since the last inspection). The home had 5 very serious requirements from the previous inspection report. The manager, deputy manager and the staff team are to be commended on the positive changes made in the home and the commitment to making the home a safer place to live in. The care at Ashlyn has never been of any great concern, but the atmosphere in the home on this visit was calmer and residents appeared happier. The home was warm and comfortable with good furnishings and a good level of decoration. The residents were cared for by a team of well-trained, skilled and caring staff. What the service does well: The home provides a warm and homely atmosphere for residents. The home has created a family type atmosphere that all of the residents spoke about. The menu in the home provides a well-balanced and varied diet for residents. The kitchen was well stocked, clean and well maintained. Ashlyn has a strong caring staff team, and has a low staff turnover; staff that have left have done so for genuine reasons. The staff group at the home are enthusiastic, well trained and skilled. Ashlyn DS0000062965.V309732.R01.S.doc Version 5.2 Page 6 All of the residents spoken with on the day stated that the manager and staff were ‘kind and caring’ and the home was ‘very nice’. Residents reported that relatives and visitors are welcomed into the home at all times. Some of the activities provided in the home are specifically designed to provide stimulation for residents with dementia including chair games to promote physical exercise and interaction with the other residents and staff. The staff were observed to chat continually with the residents and involve them as they went about their work through out the day. The home has close links with the health care team in the area, and works with both professionals and residents to promote and maintain the residents health. The home promotes the rights of the residents and staff provide care that ensures privacy and dignity. The residents interacted comfortably with the staff. What has improved since the last inspection? What they could do better: The complaint policy and procedure needs to be developed to be more understandable to the residents living in the home. Ashlyn DS0000062965.V309732.R01.S.doc Version 5.2 Page 7 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. Ashlyn DS0000062965.V309732.R01.S.doc Version 5.2 Page 8 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 Ashlyn DS0000062965.V309732.R01.S.doc Version 5.2 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an appropriate pre-admission process that ensures that the home has assessed the needs of the prospective resident. EVIDENCE: One of the four care plans examined was that of the newest admission into the home. This resident was funded by the local social service department and their file contained the social service assessment and the home’s preadmission assessment. There was evidence that the resident and their family are involved in the care planning process. The home had used its own preadmission assessments, which were comprehensive and contained an appropriate assessment of need. One resident spoken with confirmed that prior to their admission, both they and their family had been fully involved with all decision-making plans. One recent admission into the home made the following comment “the move in here was painless” and “the staff made me feel so welcome and at home, it made it easier to settle in”. Ashlyn DS0000062965.V309732.R01.S.doc Version 5.2 Page 10 Ashlyn DS0000062965.V309732.R01.S.doc Version 5.2 Page 11 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 at least once during a 12 month period. 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. Health, personal care, social and emotional needs were set out in individual care plans, and satisfactorily cover all key needs and provide sufficient details of the action required by staff. Health care needs are well met within the home, and as before care plans adequately set out residents’ health, personal and social care needs. The medication procedures protected residents. Staff treated residents with dignity and respected their privacy. EVIDENCE: Four care files were examined. All contained detailed information regarding the resident’s need, the action to address this need, and the long-term outcome of the care given. The care plans covered all aspects of a resident’s physical, mental and social needs, and were fully reviewed on a monthly basis. Where the resident has a dementing illness the care plans reflected this issue in depth. The care plans are comprehensive and detailed, the level of information Ashlyn DS0000062965.V309732.R01.S.doc Version 5.2 Page 12 is excellent, well written, informative and directive to staff. All of the care plans contained a detailed risk assessment that enabled staff to identify and manage the risk. There was evidence that residents signed care plans and were involved in the planning process. Residents spoken with confirmed that the staff in the home provided them with a good level of support and assistance. They commented “I trust the staff to give me with what I need” and that staff “do a great deal to look after all of us”. Staff were observed treating residents with care and sensitivity, addressing residents appropriately and demonstrating a genuine level of care. The care plans that were examined all contained clear and detailed instructions for the delivery of personal care for residents. Oral and foot care were fully detailed. Routine health checks offered such as optician, dentist, and podiatrist were well documented. The home provided residents with access to aids and equipment to address their healthcare needs and issues. The manager confirmed that the home is well supported by the local primary healthcare team. Two residents stated that they were confidant that staff would “phone for the GP if they were ill” and that “the staff are good at spotting if I am ill”. The manager has a registered nursing background and stated that many of the carers come from a healthcare background. This has the benefit that some healthcare issues are picked up speedily and dealt with in a preventative manner. The medication used in the home is securely locked and stored. The records of the administration, receipt, and disposal of medication are accurate and well maintained as are the records of controlled medication. The staff spoken with that are responsible for giving medication confirmed that they had received appropriate training and support, and are confident that they ensure the safety of the residents when administering medication. Through discussion with staff it was clear that they were knowledgeable regarding side effects of medication, the policies and procedures and the importance of accurate recording. The manager reported that they had a good working relationship with the pharmacist, and is able to contact him to seek advice if required. All of the residents spoken with commended the staff with regard to the treatment they received in Ashlyn. The residents stated that their privacy and dignity was maintained in a variety of ways, including the way staff provided personal care, toileting issues, respect for visitors, and the provision of private areas in the home that enabled residents to see visitors in private. Observation of staff during the inspection indicated that staff are friendly, considerate and respectful toward residents. Residents and relatives commented that the “staff are wonderful” and “respect me as a person” and “treat me with respect at all times” “they treat my Dad so well he does not like to leave the home in case he misses something”. The residents confirmed that the home’s routines were Ashlyn DS0000062965.V309732.R01.S.doc Version 5.2 Page 13 relaxed and that this made them “feel even more at home, as I can do virtually anything I did before I lived here”. Ashlyn DS0000062965.V309732.R01.S.doc Version 5.2 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides an environment that meets the social and recreational preferences of the residents. There is a full range of activities to meet the residents’ varying needs. The home provides the residents with flexibility and choice with regard to their daily lives. Their expectations and preferences with regard to lifestyle are well met. Residents are provided with a wholesome, nutritional and appetising diet. The residents are enabled to exercise choice over what they eat. EVIDENCE: The home’s activity programme offered a wide variety of social activity that was appropriate to the needs of the residents. The care plans sampled detailed the social and leisure needs of the residents. The residents were observed spending time in various parts of the home, communal areas and in their bedrooms. Residents confirmed that they were consulted regarding the entertainment brought in from the outside and that they were consulted prior to any changes being made. Residents spoken with confirmed that the home Ashlyn DS0000062965.V309732.R01.S.doc Version 5.2 Page 15 provided a variety of activities in line with their preferences. Three residents confirmed that “there was always something to do” and one resident stated that, ”I do some of the activities” and “the lady who does the activities is great”. Residents spoken to confirmed that they felt that they had choices in their daily lives (e.g. where and how to spend their day, what to eat, when to go to bed, etc.). On the day of the inspection, residents spent time in various parts of the home undertaking different activities both formal and informal. Residents commented that there “were no restrictions on them”. Resident choice is observed throughout the day and the staff are supporting choices made by residents rather than making choices for individuals. Staff are very clear regarding this issue and stated that the policy of the home is that the care is resident led. The staff are pleasant, polite and professional with their dealings with the residents and provide care in a discreet and quiet manner. The atmosphere in the home is calm and soothing and is suitable to the residents needs. The manager confirmed that the home does not act as appointee for any of the residents living there. Arrangements for residents to bring in possessions were discussed prior to admission, and records of possessions are available. The care plans examined indicated some personal preferences in terms of food, clothes and other daily choices. Routines in the home are flexible and residents’ individual choices where possible, are addressed. One resident commented that they felt that they were “free to come and go as I pleased”. Staff confirmed that they encouraged residents to leave the home with relatives, and encouraged relatives to attend events held in the home. The 4 weekly rota’d menu examined reflected that the home provided residents with a variety of well- balanced, nutritional and high quality meals. The kitchen was well organised, and the food stocks were high and of good quality. Meals are freshly prepared and cooked by the chef who has a great deal of experience. The chef was knowledgeable and skilled and was committed to providing good wholesome meals to the residents. The meal presented on the day was appealing and was served with refreshments. The residents stated that the quality of food in the home was “excellent”. Residents confirmed that the meals provided in the home were “good, appetising and more than enough” and “fantastic, great choice and well cooked” and “the cook was very capable”. Fresh fruit and snacks are available throughout the day, and residents confirmed that they could have a drink or snack at any time. When required, meals are served ‘softened’ and special dietary needs are catered for. Ashlyn DS0000062965.V309732.R01.S.doc Version 5.2 Page 16 Ashlyn DS0000062965.V309732.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. 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 an appropriate procedure for responding to complaints, but the home’s complaints’ record did not provide satisfactory evidence of how complaints were investigated or resolved. The home promotes the protection of service users through its policies and procedures and through staff training; however, evidence of training to promote staff awareness of protecting residents from abuse was not yet sufficient to demonstrate that all staff had received this training. EVIDENCE: The home has a Complaint procedure that is displayed in the foyer of the home. The document directed the individual on how and to whom, to make a complaint. It contained timescales for action, and the details of the CSCI. It was a long-winded document and was not considered user friendly. All of the residents confirmed that they were aware of the existence of the Complaint procedure, and they were able to confirm that they knew who to complain to, and felt confident that their concerns would be dealt with immediately. The home’s complaint log was well maintained and confirmed that three new complaints had been received since the previous inspection. Evidence indicated that the complaints were well recorded and dealt with in a professional manner. Ashlyn DS0000062965.V309732.R01.S.doc Version 5.2 Page 18 The Protection of Vulnerable Adult abuse policy and procedure examined on the day was suitable for the purpose of protecting residents. The document had detail regarding the signs or types of abuse and contained clear and detailed information for staff. The home has a whistle blowing policy and procedure available to staff, that ensures their protection should they report bad practice. The training records reviewed on the day confirmed that all staff except the new staff had received adult abuse training. The manager reported that the home had not had any reported allegations of abuse since the previous inspection. Ashlyn DS0000062965.V309732.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a safe, well-maintained environment, which on the day of the site visit was clean and hygienic. Residents have access to safe and comfortable indoor and outdoor communal facilities. Bedrooms viewed were clean and well maintained, with suitable furniture and furnishings. EVIDENCE: The home continued to appear safe, clean and in a satisfactory state of decoration and repair. Records of decoration and refurbishment were not inspected on this occasion: monthly reports on the home sent into the CSCI by the registered provider over the course of the last year showed regular maintenance of the home taking place. The home has a maintenance person, and both he and the manager oversee the maintenance and safety of the premises. Communal lounges are homely. The home has a secure garden area, which is well maintained and laid out. During the course of the site visit, Ashlyn DS0000062965.V309732.R01.S.doc Version 5.2 Page 20 residents were seen to be sitting outside enjoying the sunshine, and it was good to see appropriate seating and protection from the sun being provided. Four bedrooms were viewed: these were similarly clean and tidy, with furniture and furnishings appropriate to the needs of residents, and well personalised. One relative stated that a key factor in them choosing this home was the homeliness of the rooms. The home’s laundry is sited outside of the main building and away from areas where food is stored or prepared. Washing machines had the facility to carry out sluice and wash cycles suitable for infection control purposes when washing soiled linen, and the laundry person was aware of which cycles to use, and of the importance of wearing protective clothing when handling laundry. The home has separate sluice rooms on both floors of the home; these were not inspected on this occasion. Infection control policies and procedures were not reviewed on this inspection; protective clothing was seen to be available to care staff. Ashlyn DS0000062965.V309732.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels (number and competence) are sufficient to meet the needs of current residents. There is a stable and loyal staff team, which ensures consisitency in the delivery of care. The recruitment procedure in the home is robust and ensured the safety and protection of the residents. Residents benefit from a well trained staff team. EVIDENCE: The staff rota examined reflected that the home was providing the agreed level of staffing. The home had an appropriate number of day care and night care staff and additional numbers were on duty during busy periods. The home does not use agency staff to cover absence as it will use a member of the permanent staff team or a member of the bank staff ready to work on stand by, this results with the consistency of staff available to residents. Ashlyns provides staff with a full and appropriate annual training programme. Of the thirty-six members of staff, eight have achieved their NVQ Level 2 or above, and there are plans to have the remaining staff apply for the course this year. The manager is aware that that the number of staff with their NVQ level 2 or above is unsatisfactory and will keep the commission informed of the progress in this area. Ashlyn DS0000062965.V309732.R01.S.doc Version 5.2 Page 22 The staff training and development programme provided in the home is of a good standard. The home provides a thorough and comprehensive induction programme for staff, which uses the Skills for Care induction standards; all staff are fully inducted within twelve weeks of their appointment. Staff have a range of refresher and specialist training available to them and are obliged to undertake refresher training when identified. The staff spoken with and staff personnel records of the two newest member of staff confirmed that all pre-recruitment checks are completed prior to employment. The staff files contained references, application forms, Criminal reference Bureau checks, personal identification, photograph and contract of terms and conditions for staff. The file of the two newly recruited employee confirmed that she had received a full induction programme, and had shadowed a senior care worker until she was assessed as fit to work alone. The manager is fully aware of all the checks that are needed prior to the employment of staff. Ashlyn DS0000062965.V309732.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33,35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run by a competent and skilled manager. The home has an effective system in place to ensure that the quality of the service is reviewed and monitored. The home has systems in place that safeguards the residents’ financial issues. There were comprehensive health and safety systems in operation to ensure the ongoing welfare of both residents and staff. EVIDENCE: The manager of the home has recently been registered with the Commission for Social Care Inspection. The manager has a wealth of experience in the Ashlyn DS0000062965.V309732.R01.S.doc Version 5.2 Page 24 social care industry and is knowledgeable and skilled. The staff report that they are confident in the managers skills, trust her and find her “fair but firm” and “ready to listen”. The manager is slowly gaining the trust of the majority of the care team who view her leadership as a positive issue for the home. The home had an established quality assurance system in place. The residents and representatives are involved in the user surveys and the information gathered from those surveys has been used to enhance residents’ lifestyles within the home. The home plans to survey the staff working in the home. The home holds limited amounts of personal allowance for residents. The personal allowances of four residents were inspected on the day and all four were found accurate and well maintained. The home provides staff with appropriate Health and Safety training. Risk assessments of the premises were undertaken and regular Health and Safety checks of facilities and equipment were completed. The manager was aware of relevant Health and Safety legislation and was committed to the welfare of both the residents and staff group. Hot water, fire alarm and equipment checks were accurate and up to date. The staff spoken with were aware of the policies and procedures regarding Health & Safety issues. Ashlyn DS0000062965.V309732.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Ashlyn DS0000062965.V309732.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 OP16 Refer to Standard Good Practice Recommendations The registered person must ensure that the home’s complaint policy and procedure are user friendly and are in a format that is easy to read and understand. Ashlyn DS0000062965.V309732.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 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 Ashlyn DS0000062965.V309732.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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