Inspection on 18/09/07 for Ashmore House

This inspection was carried out on 18th September 2007.

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

Ashmore House 16/07/08

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Ashmore House 99 Carlton Hill Herne Bay Kent CT6 8HR Lead Inspector Eamonn Kelly Unannounced Inspection 18th September 2007 10:15 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 Ashmore House DS0000069412.V346358.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. Ashmore House DS0000069412.V346358.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashmore House Address 99 Carlton Hill Herne Bay Kent CT6 8HR 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) 01227 365420 s_ramchurn@hotmail.com Mr Baboo Ramchurn Mrs Gowree Ramchurn Mr Baboo Ramchurn Care Home 9 Category(ies) of Old age, not falling within any other category registration, with number (9) of places Ashmore House DS0000069412.V346358.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Ashmore House provides residential accommodation for up to 9 older people. Bedroom accommodation is on the ground and first floors with access to the first floor via stairs and stair lift. Five bedrooms are single and two are shared. Five residents (two in a shared room) live on the first floor. Four live on the ground floor (two in a shared room). Weekly fees are from £312-£346. Additional charges are made for hairdressing, chiropody, newspapers and private phone costs. The revised resident’s guide contains information about services and facilities. Ashmore House DS0000069412.V346358.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on 18th September 2007. It consisted of meeting with the owners, residents and members of staff. Care practices were observed and discussed with members of staff. A variety of records was seen during the visit principally those that supported the care of residents. Mr Ramchurn provided the commission with a completed annual quality assurance assessment (AQAA). Five relatives and one resident returned completed questionnaires about their views of the service to the commission. These acknowledged improvements made to the service by Mr and Mrs Ramchurn. This report contains information about progress over the past 6 months since the new owners acquired the business. Suggestions are included below about areas that could be developed for the benefit of staff and residents as part of quality assurance measures. What the service does well: What has improved since the last inspection? What they could do better: All residents should receive a copy of a personal contract that includes the rights and responsibilities of both parties. Full pre-admission assessments should be carried out. These should include a description of the actual support necessary to meet the prospective resident’s assessed needs. This information should form the basis of the subsequent care plan and the care plan should then become an active operational tool for the owners and members of staff. Ashmore House DS0000069412.V346358.R01.S.doc Version 5.2 Page 6 The high dependency levels of most residents including those needing 2:1 attention day and night means that care staff are under pressure in supporting them. There should be greater efforts to improve the mobility of residents. This needs, for example, sufficient effort to help residents use the communal bathroom rather than have constant resort as now to commodes. Residents also need sufficient encouragement to, for example, dress each day and have their meals in the dining room. A procedure should be in place for obtaining resident’s preferences for mid-day and evening meals, recording the preference and ensuring that residents receive the meal requested. Medication procedures should be reviewed and, where necessary, improved. As part of this suggested improvement, medicines should be stored in a suitable lockable mobile trolley. All aspects of safety procedures should be reviewed, for example, portable appliance tests at admission stage and annually thereafter, infection control procedures, and the policy and procedures relating to safe moving /lifting of frail older people. 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. Ashmore House DS0000069412.V346358.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 Ashmore House DS0000069412.V346358.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): 1, 2, 3, 6. People who use the service experience good quality outcomes. This judgement was made using a range of evidence including a visit to the service. Prospective residents and their supporters receive initial advice and guidance to help them assess the quality, facilities and suitability of the home. This includes provision of a resident’s guide that describes services and facilities. EVIDENCE: Prospective residents and their representatives receive assistance and guidance to enable them to decide if the home is able to meet their support needs. They receive a guide that contains information about services and facilities. Most residents have not yet received a personal contract. In providing an updated personal contract to all residents, the opportunity should be taken for the benefit of residents and their supporters to ensure that it contains full relevant information on the rights and responsibilities of both parties. Ashmore House DS0000069412.V346358.R01.S.doc Version 5.2 Page 9 Mr and Mrs Ramchurn carry out an assessment of prospective resident’s support needs with assistance if appropriate from Social Services’ care managers. A number of residents have support needs associated with the onset of dementia care as well as substantial mobility problems needing support by 2 members of staff. The care plan record begun at this stage should state the support needs of the prospective resident and how these needs will be met. The admission procedure should be reviewed to ensure that new admissions are made in accordance with the home’s registration. The premises are not suitably equipped or staffed for the purpose of providing intermediate support (short-term recuperative care). Long-term care and short periods of respite care for residents are provided. Ashmore House DS0000069412.V346358.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7-10. Residents who use the service experience adequate quality outcomes. This judgement was made using a range of evidence including a visit to the service. Residents receive good healthcare and personal support and care plan records assist in progressing this care. However, better mobilisation of residents and less isolation is necessary for their physical and mental wellbeing. Some improvement in medication administration would be of benefit to staff and residents. EVIDENCE: The new care plan system has a great deal of information about residents support needs but it does not act as a sufficiently effective operational tool for staff. Members of staff indicated that, whilst they complete a daily record at the end of shifts, they generally do not contribute to the upkeep of care plans. There is good information about resident’s background but it is difficult to read. Mr Ramchurn says that staff will be increasingly involved, as suitable training takes place, in the preparation and upkeep of care plans and support tools such as weight charts, Waterlow scores and risk assessments. Ashmore House DS0000069412.V346358.R01.S.doc Version 5.2 Page 11 Most residents were in their bedrooms during the inspection and most receive their meals there. This isolation is not in keeping with better practices for supporting people who have extensive support needs including the on-set of dementia and need for attendance by 2 members of staff. Care plan records make a good attempt at reflecting resident’s support needs and how these needs should be/are being met. There is widespread use of commodes and limited bathing (once a week according to a bathing list). The ground floor room said to be potentially available as a dining room is not used for this purpose as it is not suitably laid out or equipped. This results in residents receiving their meals on a tray either in the lounge or in a bedroom. It is said that residents have chosen this pattern of support. It is said that efforts are made to mobilise residents but with limited success because of their advances age and preferences. In one situation this choice exercised by a resident is in the resident’s overall best interests. In other cases, the culture of the home and the nature of the premises dictate the general pattern of activity for staff and residents. Mr and Mrs Ramchurn have recognised and are addressing this problem that they believe existed when they bought the business. Residents have access to local NHS community services, including GPs and health care professionals. There is close contact with local PCT nurses who advise on skin care and provide dressings. Mr Ramchurn indicated that, in the months since he bought the business, healthcare support had to been greatly improved. Care plan records evidence these improvements. Medicines are stored in locked cupboards in the kitchen and hall. Medication records are completed when administration takes place. Some medicines are kept in bedrooms. No controlled drugs are kept at the premises so special facilities are not required. An up-to-date photograph of each resident will be kept with his/her MAR sheet. There is a very large amount of medicines stored at the home (mostly in blister packs) and some unused medicines had not been disposed of suitably. A mobile medicine trolley and improvements in medicine administration would be of benefit to residents and staff. During the inspection visit, members of staff treated residents with understanding and respect. Ashmore House DS0000069412.V346358.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12-15. Residents who use the service experience adequate quality outcomes. This judgement was made using a range of evidence including a visit to the service. Residents receive some support in keeping physically and mentally active. They would benefit further from assistance and encouragement to remain more mobile. Meals should be provided in a more acceptable and congenial setting. EVIDENCE: The majority of residents are aged 84-96. The annual quality assurance assessment (AQAA) states that no residents are “bed fast” (ie. confined to bed). Virtually all need help with dressing/undressing, with washing/bathing and with going to the toilet. Four need assistance with eating. One has very significant hearing and vision impairment. Several are singly or doubly incontinent. One resident needs the attendance of two members of staff day and night. The assessment indicates that no residents have dementia or other mental health needs. This self-assessment assessment is not borne out by the evidence of the inspection. Some residents have the on-set of dementia and have mental health difficulties such as depression. Ashmore House DS0000069412.V346358.R01.S.doc Version 5.2 Page 13 Residents would benefit from support that addresses their needs on a day-today basis and increases their mobility, reduces their exposure to isolation and helps to improve their mental and physical alertness. The quality assurance self-assessment submitted to the commission by Mr Ramchurn outlined the range of indoor activities provided and stated that, over the next 12 months, these would be improved and contact may be made with local ministers of religion if residents request this. Members of staff have a good understanding of each resident’s personality and, for example, where a resident has very significant hearing impairment and is blind a member of staff communicated very effectively with the resident and made sure the resident was comfortable. Members of staff have very good contact with residents and work hard to keep them engaged with conversation and other interactions. The majority of residents stay in their bedrooms and receive their meals there. Instances were discussed during the inspection visit where the outcome of care for some residents is not good because of their isolation. Later in this report, reference is made to the need for further training for all care staff in assisting people with dementia and other mental health difficulties and understanding why they may be behaving as they do. All residents received the same main meal at 12.15 pm delivered under covered plates. They are not requested the day before to indicate any choice. Residents say they have come to accept what is provided and some say they feel lucky to be receiving this attention. Members of staff say that residents are offered some choice for evening tea and that this always includes a hot meal at this time. A record is kept where residents have eating problems and supplement drinks (ensure) are provided. The dining room is not laid out as a dining room for residents and is used as a meeting room. The provision of meals does not take place in congenial surroundings and residents in their last years are deprived of this important amenity. Residents may receive visitors at any reasonable time and the home encourages this continuing contact. The five respondents (relatives/supporters) to the commission’s survey indicated they are satisfied with the support provided by the home. Ashmore House DS0000069412.V346358.R01.S.doc Version 5.2 Page 14 Ashmore House DS0000069412.V346358.R01.S.doc Version 5.2 Page 15 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. People who use the service experience good quality outcomes. This judgement was made using a range of evidence including a visit to the service. Residents are protected from abuse by the vigilance of owners and staff. EVIDENCE: Residents and visitors are involved in saying how improvements would be of benefit to them. Mr Ramchurn says this is taking place as part of new quality assurance measures. Copies of surveys completed by relatives and residents indicated that such consultation takes place. The service has a complaint’s procedure that is understood by staff, residents and relatives. Reference to this is also included in the resident’s guide. The annual quality assurance assessment (AQAA) submitted by Mr Ramchurn to the commission states that members of staff are aware of all the necessary procedures relating to protection of residents via their attendance on NVQ Level 2 in Care training. Specific training on the wider implications of POVA (protection of vulnerable adults) forms part of the improvements in staff training and development being put in place by Mr Ramchurn. The commission received one complaint relating to procedures at the home. Mr Ramchurn addressed the issue in an appropriate way. Ashmore House DS0000069412.V346358.R01.S.doc Version 5.2 Page 16 Ashmore House DS0000069412.V346358.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24, 26. Residents who use the service experience adequate quality outcomes. This judgement was made using a range of evidence including a visit to the service. The premises are broadly suitable for use by frail older people. EVIDENCE: The premises have 5 single and 2 shared bedrooms. Five residents live on the first floor and four are accommodated on the ground floor. The premises have a stair lift. The garden is suitable for use by frail older people. Resident’s bedrooms are comfortable and well equipped as is the lounge. The room regarded as the resident’s dining room is not used for this purpose. Residents receive their meals individually on trays that they access from their chairs in bedrooms and lounge. These arrangements are not ideal. Ashmore House DS0000069412.V346358.R01.S.doc Version 5.2 Page 18 Radiators are covered for the safety of residents. Hot water outlets accessible to residents are temperature controlled and are manually checked each week for safety reasons. Two fridge/freezers and a separate freezer are located in the hall of the premises opposite bathing and toilet facilities. The positioning of this equipment is not ideal. A domestic worker attends on weekdays to help to keep the premises clean and to prevent infection. There were no odours that were not being kept under reasonable control. Clinical waste is transferred to yellow sacks stored at the front of the premises. This waste should ideally be stored in a yellow bin obtainable from the collection company. Ashmore House DS0000069412.V346358.R01.S.doc Version 5.2 Page 19 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): 27-30. Residents who use the service experience good quality outcomes. This judgement was made using a range of evidence including a visit to the service. Residents are in the care of a staff group that are enthusiastic and hardworking. Members of staff are receiving opportunities for personal development to enable them to address resident’s support needs. EVIDENCE: Both owners live at the premises and share night-time care duties. They are often present during the day to support care staff. Two carers are on duty between 8am-6pm. One carer and the owners are present after 6pm. A domestic worker is present during weekdays between 9.30-11.30am. The high dependency needs of residents and the facilities of the home suggest that members of staff are stretched in maintaining good mobility levels of residents. A check of staff files indicated that applicants complete application forms, references are taken up and CRB checks are carried out. The small problem identified was that, in one case, only one written reference was taken up. The owner will seek a minimum of 2 references in future. Mr Ramchurn carries out formal supervision at appropriate intervals. Good progress is being made on staff development. Soon all carers will have completed NVQ Level 2 in Care. Ashmore House DS0000069412.V346358.R01.S.doc Version 5.2 Page 20 The standard required by the relevant training organisation for the care sector (Skills for Care) in respect of induction is not yet being met. However good progress also is being made in this regard. All members of staff have not yet received adequate training in the subjects regarded as “mandatory” including safe movement and handling of frail older people. Some residents have significant mobility difficulties. From a description of staff awareness about how to deal with residents who might have fallen, the evidence is that members of staff are unlikely to be aware of the correct procedure to follow for the safety of residents. This is evidenced by the presence of a lifting sheet and straps stored in the first floor bathroom. Some staff referred to the unsatisfactory nature of the short training sessions (on moving/lifting residents) provided by a training agency. Mr Ramchurn requires all carers to have attained, be attaining or be prepared to complete a relevant NVQ (2 or 3 in Care). The home is working towards enabling staff to receive proper induction and “mandatory” training so their skills are such that the support needs of residents are professionally and consistently met. The overall template discussed with Mr Ramchurn as being the objective is as follows: • Registered Manager’s Award. Mrs Ramchurn is undertaking this qualification. Mr Ramchurn has undertaken training in care and management that meets current requirements for registered managers. Skills for Care Level Induction. For all members of staff. Staff Supervision & Appraisal. For staff undertaking formal supervision every 6-8 weeks. Adult Protection/POVA: Updates to be provided in-house as legislation and/or NMS/regulations require. For all staff. NVQ Level 2 in Care. For all carers. Level 3 might be available for carers who wish to progress their knowledge and skills. Safe Handling of Medication. For staff with any responsibility for administration of medicines. Food & Hygiene: Staff must have food hygiene training. (eg. 1-day by the Borough Council. Lasts for 2 years). However, the better option for carers is “Food & Nutrition”. [NCFE Certificate in Food & Nutrition]. NVQ Level 1 in COSHH. For staff providing domestic support and NVQ Level 2 in Domestic Cleaning. For staff providing domestic support. Certificate in Safe Movement of Vulnerable People (Manual Handling): Valid for 5 years. Annual half-day updates. For all carers. This should include safe operation of hoists. NCFE Certificate in Infection Control. (a) Infection Control. Valid for 3 years. This relates to the law, who to report to, contamination etc. (b) Cross Infection: This is about bodily fluids, disposal of materials, laundry DS0000069412.V346358.R01.S.doc Version 5.2 Page 21 • • • • • • • • • Ashmore House • • etc. Carers and domestic staff should preferably receive training in infection control and cross infection. Fire Training: In-house by reputable company. At induction. And for all staff every 6 months. First Aid: Full 3-day course or 1-day “appointed person” course. Renewable after 3 years. A first-aider should be on duty during each shift. Specialist training in specific topics (diabetic conditions, Parkinson’s disease, mental health and depression, maintenance of hearing aids, aids for blind or partially blind people, skin integrity, mobility problems in old age) would in due course be of benefit to carers and therefore to residents. Members of staff are hardworking and enthusiastic. The outcomes for some residents who have the on-set of dementia and mobility difficulties are not good. Many people are isolated and alone although members of staff seek to keep them comfortable and involved. When sufficient progress has been made over the next 12 months in achieving the levels of staff training and development that Mr Ramchurn is aiming towards, some members of staff may progress towards achieving the RVQ Certificate in Dementia Care. This would benefit staff and residents. Ashmore House DS0000069412.V346358.R01.S.doc Version 5.2 Page 22 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. Residents who use the service experience adequate quality outcomes. This judgement was made using a range of evidence including a visit to the service. Residents have the benefit of living in premises where the owners are addressing the need to make improvements so that the home is run in the best interests of residents. EVIDENCE: The registered owners are registered nurses (RGN). Mrs Ramchurn is completing the Registered Manager’s Award and Mr Ramchurn has achieved NVQ Level 4 in care and management. He was previously a hospital staff nurse and district nurse. It is clear that resident’s access to better healthcare facilities has improved since Mr and Mrs Ramchurn took over the business earlier in the year. Their commitment to quality assurance measures is likely to improve the comfort of residents and their longer-term care and support. Ashmore House DS0000069412.V346358.R01.S.doc Version 5.2 Page 23 The home does not hold cash on behalf of residents. Where residents receive services that are additionally charged for, they are invoiced every 2 months. Receipts are kept and accounts of all transactions are maintained. The policy of the home is that residents or a main supporter retain responsibility for their financial and legal affairs. Mr Ramchurn made a declaration in the annual quality assurance assessment (AQAA) that all safety certificates and checks are in place and up-to-date. This included the statement that all electrical appliances receive annual checks by an electrician and that appropriate certificates are maintained. Fire safety procedures are followed and fire safety records are, according to the AQAA, up to date. However, the self-assessment contained no declaration in respect of the initial and then annual checking of portable electrical equipment and disposal of waste materials. Mr and Mrs Ramchurn are improving and developing systems that monitor practice and compliance with the plans, policies and procedures of the home. They know that more work is needed in this area. Mr Ramchurn is aware of the need to promote safeguarding and has developed a health and safety policy that generally meets health and safety requirements and legislation. He is aware of the need to plan the business activity of the home and manage the finances and resources to deliver the business plan. The home has a significant burden in maintaining a good service within the limitations of current fees and the nature of the premises. Checks show that records are generally up to date although some gaps are found in recording and entries are not always clear. Care plan records are extensive but are not yet fully effective in being good operational tools for staff. Ashmore House DS0000069412.V346358.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 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 3 2 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 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 2 x x x 3 x 2 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 2 x 3 x x 2 Ashmore House DS0000069412.V346358.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Not applicable 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. Refer to Standard Good Practice Recommendations Ashmore House DS0000069412.V346358.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Ashmore House DS0000069412.V346358.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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