Inspection on 06/02/08 for Ashmill

This inspection was carried out on 6th February 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Ashmill 23/06/09

Ashmill 23/04/09

Ashmill 25/08/06

Ashmill 22/11/05

Ashmill 02/06/05

Ashmill 07/01/05

Ashmill 01/07/04

Ashmill 26/01/04

Ashmill 07/08/03

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

CARE HOME ADULTS 18-65 Ashmill 141 Millfield Road Handsworth Wood Birmingham West Midlands B20 1EA Lead Inspector Loraine Dunkley Key Unannounced Inspection 6th February 2008 10:15 Ashmill DS0000016719.V355045.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 Ashmill DS0000016719.V355045.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. Ashmill DS0000016719.V355045.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashmill Address 141 Millfield Road Handsworth Wood Birmingham West Midlands B20 1EA 0121 358 6280 0121 358 6280 ashmill141@hotmail.com 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) Ashmill Residential Care Home Ltd Alison Shaughnessy Care Home 18 Category(ies) of Physical disability (18) registration, with number of places Ashmill DS0000016719.V355045.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 25th August 2006 Brief Description of the Service: Ashmill is registered to provide personal care and support to 18 adults with a physical disability, who have been assessed as requiring full assistance with daily living tasks. The service is staffed twenty four hours a day including two waking night staff. The full range of medical services, leisure and social activities are provided for people living at the home. A number of adaptations are in place in order to meet peoples assessed needs. People who live at Ashmill are encouraged and supported to maintain links with their families and the local community. The service is situated in the Handsworth Wood area of Birmingham in a quiet residential road. It is close to local amenities and there is parking available at the front of the premises. The fee for this home is £650.00-£850.00 per week. Additional charges include those for aromatherapy, hairdressing and chiropody. Ashmill DS0000016719.V355045.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection, which took place over one day. Before the inspection two people living at the home agreed to act as link resident for the inspection helping us to distribute surveys, and ensuring that they were returned to us. The service also send us their annual quality assurance assessment, this was sent to us on time, and gave us detailed information on how the home is meeting the needs of people living there. During the inspection visit we looked at records, spoke to a number of people living at the home, two of their relatives, staff, the manager, and looked around the home. We received surveys from 11 people living at the home, 5 of their relatives, and 4 staff, we have used their views throughout this report to help us in making a judgement on how the home is meeting outcomes for people living their. Everyone at the home gave their full cooperation during the inspection, and we would like to express our thanks to the two people who acted as link residents. The quality rating for this service is 2 star. This means that people who use this service experience good quality outcomes. What the service does well: People living at the home and their relatives have told us that: “I think the standard of care is excellent. The meals are really nice.” “The home is always fresh and clean. Ashmill is a fantastic home, the best. Ashmill is situated in a nice area, it’s a great home to live in.” “My son is very happy here he is looked after very well. It feels like home form home for me and my husband.” “Staff try to make life as independent as possible for the residents. I couldn’t ask for better love and care. The relief of knowing my daughter is well looked after, I can sleep at nights knowing she is well and safe.” The home is well managed, at the time of inspection the atmosphere in the home was clean, warm and friendly. People talked a lot about the activities they were involved in. The records were organised and well kept. The home caters for people from different cultural backgrounds. Ashmill DS0000016719.V355045.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Ashmill DS0000016719.V355045.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 Ashmill DS0000016719.V355045.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): 1,2, 5 Quality in this outcome area is good. People have access to the necessary information they need to help them make informed choices about moving into the home. People receive an assessment of their needs before they are admitted into the home, although further information from the funding authority would enhance this process. Everyone has a contract with the home, setting out the terms and condition of living in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager states that everyone has a copy of the service users guide, which is kept in their rooms. The service users guide was reviewed in September 2007, this now contains details of the weekly charges for living at the home. The care records of three people who us the service was looked at, the records contained an assessment of needs completed by the home, but not the needs assessment completed by the funding authority. The manager says that an assessment is always completed by the home before people are admitted to live at the home, and was able to show one other record which had an assessment completed by the funding authority. The manager says regular reviews of the care is undertaken by the home, at least six monthly, but these are not documented and it was not always possible to get the local authority to undertake the necessary review, although these had started to improve, and on the day of the inspection, a social worker was in the home undertaking Ashmill DS0000016719.V355045.R01.S.doc Version 5.2 Page 9 reviews of care. No new people had moved into the home since the last inspection. The manager needs to obtain a full assessment of needs from the funding authority for any new residents admitted to the home. This will ensure that the home has all the relevant information needed to determine if they are able to meet people’s needs, and to keep a record of the care reviews undertaken by the home to show that peoples changing needs are always incorporated into their care plans. All the records looked at had a written contract between the home and the person living there, as well as a placement agreement. Ashmill DS0000016719.V355045.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): 6,7,8,9 Quality in this outcome area is good. People living at the home are confident that their needs are being met. Most areas of risks associated with peoples care are assessed, and plans are in place for managing any risks identified, although minor improvement is needed to risk assessments. People living at the home are involved in making decisions about the running of the home This judgement has been made using available evidence including a visit to this service. EVIDENCE: The three care records sampled contained a copy of a care plan completed by the home, as well as a plan of care from the funding authority. The care plans completed by the home contained details of the persons needs such as personal history, medical conditions, communication needs, drinking and eating, social activities, personal preferences other information about the persons personality, medication list, and personal goals. The care plans did not contain any information about whether people were able to control their own Ashmill DS0000016719.V355045.R01.S.doc Version 5.2 Page 11 medication. Both care plans and needs assessments had details of peoples diversity needs, such as their religion, and cultural requirements, e.g. one care plan looked at states the person required Halal meals. Discussion with the person and their relative confirmed that this dietary expectation was provided by the home, and they were happy with the meals provided. The person said, “I like curries and the home provides this.” No information about peoples sexuality, and the need to maintain personal relationships was seen on the care plans, although the manager states that one person living at the home regularly had a partner to stay. The manager says regular reviews of the care is undertaken by the home, at least six monthly, but these are not documented and it was not always possible to get the local authority to undertake the necessary review, although these had started to improve, and on the day of the inspection, a social worker was in the home undertaking reviews of care. There was information on the records to show that people had signed to say they were involved in developing their care plans. One relative said: “Staff try to make life as independent as possible for the residents. I couldn’t ask for better love and care. The relief of knowing my daughter is well looked after, I can sleep at nights knowing she is well and safe.” One person spoken with said: “I wouldn’t leave the home they would have to throw me out the carers are brilliant.” This shows hat people living at the home and their relatives are generally confident that their needs are being met by the home. During the inspection we had the opportunity to speak to a number of people living at the home, they talked freely about the opportunities for being involved in activities such as going to college, and pursuing their pastime. The home has regular meetings with the residents, and copies of the records of these meetings were sampled, these included discussions on various aspects of living at the home. The manager said people living at the home were recently involved in selecting new staff for the home, and that they had recently had a hot tub fitted, and the residents were involved in making this decision. Two people living at the home agreed to act as link resident for this inspection, both said they had enjoyed the experience. The manager said they had taken a real interest in the inspection process, and this had encouraged other residents to participate, and have an interest in meeting the inspector during the visit. All the records looked at contained evidence of risk assessments, which included manual handling, use of cot sides, accessing the community, behaviour, medication and plans for reducing the risks identified. One record looked at showed that the person was prone to elliptic fits, this was also included in the risk assessment. The risk assessments seen did not cover specific aspects of the personal care, such as bathing, showering etc. The risk assessments seen indicated that they had been reviewed regularly. Ashmill DS0000016719.V355045.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): 12,13,14,15,16,17 Quality in this outcome area is good. People living at the home have access to community activities, and are not subjected to unnecessary restrictions, people are able to maintain positive relationships with their friends and relatives. People are offered healthy and nutritious meals, which meets their cultural and medical needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Manager said a daily activity log is now in place, a record of the log was seen, this included activities such college and day centre timetable, socialising going out and watching DVD’s were recorded. The College also visits the home one day a week to do art and crafts with the residents; the college was visiting the home on the day of the inspection. Ashmill DS0000016719.V355045.R01.S.doc Version 5.2 Page 13 There is an activity coordinator at the home, discussion with this member of staff confirmed that she works closely with a local college to help people living at the home access this community resource. People living at the home were observed discussing planned outings with the manager, such as attending concerts, and the dog tract. One person spoken with said: “I go out to the shops and the bookies on my own, and I like to do bowling.” The home had recently installed a hot tub for residents use, and there is a sensory room for relaxation. Two relatives spoken with said they were free to visit the home any time they wished. The manager said that one person living at the home frequently have their partner staying at the home. As stated in a previous section of this report some thoughts need to be given to how the home supports people with a variety of different personal and sexual relationships. The home has an open and welcoming atmosphere. One person living at the home said: “The food is fantastic. I have special diet, they go out of the way to make sure we get the right food.” Another person was observed to be having a culturally appropriate meal, and both he and his relative said he got the food of his choice. The daily menu board was on display in the living/dining area three different choices of meals were observed, and people were seen to be having different meals. Staff were also observed supporting people who needed help with eating and drinking. The home employs two cooks, and the manager says both had received food and nutrition training. A tour of the kitchen showed that the cupboards were well stocked, and regular monitoring of fridge temperatures were being done. Ashmill DS0000016719.V355045.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 good. People living at the home have a plan of care, which includes their preferences, people living at the home have access to health care professionals, and records were available to support this. Medication is managed in a way that should safeguard people living at the home, but the home need to show that people’s independence with managing their medication is supported by the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All the care records looked at contained a plan of care, which included people’s personal preferences. All the records had details of moving and handling assessments. Staff spoken with were able to talk about how they maintained peoples privacy and dignity whilst providing personal care. There is a mix of different cultures of people living at the home. Pre inspection information provided indicates that there is an appropriate cultural mix of staff working at the home, which is in the main reflective of the people who reside at the home. Ashmill DS0000016719.V355045.R01.S.doc Version 5.2 Page 15 The records looked at contained a list of health care professionals who are involved with the people living at the home, the manager also keeps a separate record of confidential information relating to these visits. In addition there were numerous letters on the records relating to hospital visits, optician visits where necessary, attendance at nutrition services as appropriate etc. The management of medication was found to be to a good standard. An examination of the Medicines Administration Records (MAR Charts) indicated there were no gaps in recording and there were no discrepancies in balances of medication administered. The manager had developed a protocol for the administration of when required medication (PRN). The medication room was tidy, and temperature for the storage of medication was being maintained. People living at the home have a lockable cupboard in their rooms that can be used for storing of medication. However the care plans seen do not routinely include information about whether people living at the home are able to control their own medication, and the home will need to put this right in order to demonstrate peoples control in this area. Ashmill DS0000016719.V355045.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. People living at the home, and their relatives are fairly confident that their concerns would be listened to and dealt with by the manager. The home is generally able to safeguard people’s welfare through its policies and procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A record is kept of complaints received by the agency. The complaints log was viewed there was one complaint on record, this was also recorded and investigated by the local authority as a safeguarding issue. We were also informed of this complaint. People who live at the home and their relatives say they are confident that the home would address any concerns that they have, one person said: “If at any time I am not happy I will always go to the care manager.” Another person said: “Some of the staff listen, and some don’t.” Care workers who responded to the survey said they knew what to do if people had concerns about the home. The home has the necessary adult protection procedures, as well as the local multi-agency guidance. There was one record of a safeguarding investigation. Pre inspection information provided by the home indicated that the adult protection policy had been reviewed December 2007. The home has a fairly robust recruitment process, although we were not able to confirm if Criminal Records Bureau (CRB)/Protection of Vulnerable Adults (POVA) Checks were Ashmill DS0000016719.V355045.R01.S.doc Version 5.2 Page 17 done before staff commenced working. We were able to view the disclosure numbers only. Ashmill DS0000016719.V355045.R01.S.doc Version 5.2 Page 18 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. People live in a clean, and safe environment, which has been adapted to suit their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was generally clean and tidy at the time of this inspection. New tiles were being fitted to one of the corridors. One person living at the home said: “The home is always fresh and clean.” Another person said: The rooms are cleaned every day. One relative said: “Cleanliness is foremost.” Information provided before the inspection stated that improvements such as having a hydro pool fitted have been made, the home had achieved the “5H” award by Birmingham City Council for excellence in kitchen health and hygiene. A tour of the home showed that all arears of the home was clean and tidy, at the time of inspection. The hydrpool had been risk assessed, and had a maintaince shedule in place, and staff had received training on its use. Process are in palce for risk assessment of the premesis, and general Ashmill DS0000016719.V355045.R01.S.doc Version 5.2 Page 19 maintainance. The home is well adapted for people who use wheelchairs. Ashmill DS0000016719.V355045.R01.S.doc Version 5.2 Page 20 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): 31,32,34,35 Quality in this outcome area is. Adequate. People living at the home are supported by staff, who are offered and participate in training enabling them to undertake their duties effectively. The recruitment process could benefit from minor improvements in order to demonstrate that people living t the home are fully safeguarded by the process. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The last inspection indicated that staff were concerned about staffing levels at the weekends. The manager said that they have increased staff pay at the weekends, and this has improved the staffing level. A sample of the staff rota showed that there are 6 care workers and 1 senior care worker as well as the manager on the morning shifts during the week, 4 staff on the late shifts, and 2 waking night staff. The weekend rota consists of 7 care staff and 1 senior care worker in the mornings, and 3 care workers and 1 senior care worker on the late shifts. Information provided by the home states that 1 full time and 1 part time staff had left the home within the last 12 months. Ashmill DS0000016719.V355045.R01.S.doc Version 5.2 Page 21 Pre inspection information provided by the home states that 15 of their permanent staff currently have an NVQ2, with 12 people working towards this qualification. In addition there is a staff-training programme, which incorporates mandatory training. The records of three staff that had been employed since the last inspection was sampled. These contained evidence of application forms two references, staff induction, job descriptions. Photo identification. A full record of interviews was not kept, some references were not checked for authenticity, and one reference was not dated. There was evidence of the CRB number for all staff, but the original documents were not on the files, we were unable to determine if CRB/POVA checks had been done before these staff started working. We strongly recommend that the home keep sufficient records so as to be able to demonstrate that CRB/POVA checks are done before new staff starts work, in order to show that the recruitment process properly safeguards people. Ashmill DS0000016719.V355045.R01.S.doc Version 5.2 Page 22 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 good. People living at the home benefit from a well run home, which is warm and welcoming, where their views will be listened to, and their health and safety promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a qualified manager in place at the home, who is cooperative with the requirements of the regulations. The atmosphere of the home was observed to be open and welcoming. People’s relatives are free to visit at anytime, and say they feel welcome. One person’s relatives said: “It feels like home form home for me and my husband.” There is a complaint procedure in place, and people living at the home and their relatives are confident that their concerns will be listened to. One staff Ashmill DS0000016719.V355045.R01.S.doc Version 5.2 Page 23 said: “Since I have been here the manager has always communicated with staff and residents, any issues are always dealt with appropriately.” The home has a quality assurance process, which consists of Regular meetings with people who use the service, copies of these were evidenced during the inspection, The Manager says surveys are sent to people who us the service, visitors relatives and staff, a report is compiled from the result. The quality assurance report for July December 2007 was seen. The records seen were well kept, and kept in a secure manner. Fire drills and fire alarm testing were being done and recorded. Staff attended fire safety training in 2007.There was a recent fire officer report, and the manager said the requirements from this had been complied with. Water temperature checks are done weekly. Water testing for legionella was last done December 2007. Electrical safety certificate is dated 1st September 2006. Portable appliance testing was done 6th September 2007. Risk assessment of premises was done 4th October 2006,and reviewed on 12th December 2007. A record is also kept of regular servicing of the hoist. This shows that the safety of people living at the home should be fairly secured. The last inspection had identified that wheelchairs were not being kept clean. The manager was able to show records of wheel chair cleaning schedules, and the wheelchairs observed at the time of inspection appeared clean. First aid equipment was located in the home, and the manager said all senior staff had received first aid training, as well as most care staff. The accident book had four recorded accidents since the last inspection. The home keeps us informed of significant incidents affecting people who live at the home. Ashmill DS0000016719.V355045.R01.S.doc Version 5.2 Page 24 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 3 2 3 3 X 4 X 5 3 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 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 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 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Ashmill DS0000016719.V355045.R01.S.doc Version 5.2 Page 25 No 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. 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. Refer to Standard YA2 Good Practice Recommendations The manager needs to obtain a full assessment of needs from the funding authority for any new residents admitted to the home. This will ensure that the home has all the relevant information needed to determine if they are able to meet people’s needs. Keep a record of the care review undertaken by the home. The manager needs to document the details of reviews undertaken by the home. Personal relationships and sexuality where disclosed and relevant to the persons needs to be included in the care plans, as well as whether people are able to control their own medication. 3. 4. YA9 YA20 The manager needs to incorporate aspects of personal care in the risk assessments. The manager needs to demonstrate that people living at the home have control over their medication where they DS0000016719.V355045.R01.S.doc Version 5.2 Page 26 2. YA6 Ashmill 5. YA34 are able to, in a risk management framework. The manager needs to demonstrate that CRB/POVA checks are undertaken before new staff commences work. In order to show that the recruitment process properly safeguards people. Keep a record of interview and outcome. Ensure all references are dated, and checked for authenticity. Ashmill DS0000016719.V355045.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Ashmill DS0000016719.V355045.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. 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