CARE HOMES FOR OLDER PEOPLE
Ashridge Court Ltd 163 Barnhorn Road Bexhill On Sea East Sussex TN39 4QL Lead Inspector
Rebecca Shewan Unannounced Inspection 18th April 2006 09:15 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 Ashridge Court Ltd DS0000013956.V288726.R01.S.doc Version 5.1 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. Ashridge Court Ltd DS0000013956.V288726.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Ashridge Court Ltd Address 163 Barnhorn Road Bexhill On Sea East Sussex TN39 4QL 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) 01424-842357 01424-848570 Ashridge Court Limited Mrs Elizabeth Teresa Van Eugen Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34), Physical disability (34) of places Ashridge Court Ltd DS0000013956.V288726.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The maximum number of service users to be accommodated is thirty four (34). That the care home provides general nursing care to older people over the age of sixty five (65) and those with a physical disability. 5th December 2005 Date of last inspection Brief Description of the Service: Ashridge Court is located on the main road between Eastbourne and Bexhill, approximately half a mile from Little Common Village. Local amenities are accessible by public transport. Ample parking is available at the front of the property. The home is situated in well-maintained gardens that have extensive views to the rear of the property overlooking a large pond. The home is accommodated over two floors, which are accessible by a passenger shaft lift. The home comprises of 32 single bedrooms, 27 of which have en-suite facilities and one double room, with additional toilet and bathroom facilities throughout the premises. The home has specialist equipment including specialist beds, bath and lifting hoists and walking aids. The nursing centre is divided into two wings (East and West), which are staffed separately from each other. The property is currently in the process of having building works carried out to create 12 additional bedrooms to the rear of the property, although this will only accommodate a further eight residents as four of the current rooms in use will become a new dining area on the first floor of the East Wing. Other existing bedrooms will be extended to provide en-suite facilities. It is anticipated that this work will be completed by July 2006. The home is registered to provide nursing care to older people as well as those who may have a physical disability. The range of fees charged (at the time of this report) are £450 - £850 per week, with additional charges for hairdressing, toiletries, chiropody, taxi services and daily newspapers. Ashridge Court Ltd DS0000013956.V288726.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place during the morning and early afternoon of the 18th April and afternoon of 19th April 2006. Before the inspection previous inspection reports and Regulation 37 incident reports, held by the Commission for Social Care Inspection were read. The inspection of the home took nine hours. There were twenty-three residents living at the home at the time of the inspection, the organisation has chosen to keep occupancy low due to the current building works. A tour of the whole home was undertaken and the Responsible Individual, the Registered Manager, four staff, eight service users (known as residents) and one relative were spoken with, records such as care plans, policies and procedures, maintenance records and medication records were also viewed. Ten Service User Surveys were also distributed of which five were returned (one was completed by a resident’s relative). Comments received included: • • • • ‘Staff are very kind and caring’ ‘We consider ourselves fortunate to live in such a home’ ‘Building work is taking place but the disturbance is kept to a minimum’ ‘I do sometimes make mistakes in my requests (of staff) but this is explained by the staff, to our satisfaction’ The Organisation were requested to complete a Pre-Inspection Questionnaire, which was returned in a timely manner. However, contact details for resident’s Care Managers, Social Workers and Placing Authorities had not been included in this documentation. Therefore, the views of these individuals/organisations have not been obtained for the purpose of this report. What the service does well:
Residents are offered a good provision of health and personal care support by a multidisciplinary approach. Resident’s benefit from a well managed and service user focussed home. The home provides good social, cultural and recreational facilities, including a balanced diet, to residents in accordance with their wishes. Resident’s benefit from the home’s robust procedures, processes and staff training, in the event of an allegation of abuse. The home provides a good quality of accommodation with suitable Infection Control policies and procedures in place, to ensure that appropriate infection control measures are adhered to at all times. The home has a suitable staff team with the necessary skills and experience to the meet the needs of current residents. The management and administration of the home is good, with evidence of consideration being given to residents choice and opinion and the health, safety and welfare of residents and staff being protected at all times.
Ashridge Court Ltd DS0000013956.V288726.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection?
It was evidenced that the previous inspection requirement that the current Statement of Purpose and Service users’ Guide is displayed within the home, had now been met. Documentation relating to pre-admissions were viewed and it was noted that the previous inspection requirement that: the home review its pre-admission assessment document to ensure that it allows the assessor to gain thorough details of individuals medical, social and personal care needs has now been met. Care plans were viewed and it was evidenced that the home had complied with the previous inspection requirements that all residents must have a plan of care to ensure that all aspects of health, personal and social care needs are met. Details of any specialist interventions required e.g. for the management of nutrition, pressure area care and wound dressings are specified and recorded in residents care plans. From the records viewed and from discussions with the Registered Manager it was evidenced that the previous inspection requirement and recommendation that residents wishes concerning terminal care and arrangements in the event of death are determined and recorded and that the home compile written information specifically for residents and their relatives in relation to determining their wishes in the event of terminal care and following death have now been met. The home has received one verbal complaint since the previous inspection. Records of all verbal complaints are now recorded and these were made available for inspection. Therefore the previous inspection requirement that a record of all verbal complaints is kept and made available for inspection has now been met. It was evidenced that the home’s Adult Protection Policy has been amended, therefore the previous inspection requirement that the home updates its Adult Protection policy and procedure in line with local multi-agency guidelines, it needs to state that Social Services are now the lead agency and provide the relevant contact details has now been met. The previous inspection recommendation that the Registered Manager consult with the home’s professional body in respect of the new Common Induction Standards issued by Skills for Care (replacing TOPPS) has now been met. The Registered Manager is currently in consultation with Greenwich University with regards to Common Induction Standards and one staff member has completed two modules of the training course. The previous inspection recommendation that the home considers the reasons as to why response from residents questionnaires is low and revise if
Ashridge Court Ltd DS0000013956.V288726.R01.S.doc Version 5.1 Page 7 necessary has been revised and poor responses to previous questionnaires have been discussed with residents and it was reported that residents felt that they did not have to provide written responses as they deemed their verbal feedback as being sufficient. The home has made some improvements to ensure that all policies and procedures have been amended to provide the current contact details of the CSCI and have been adapted in order that they are specific to the home. 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. Ashridge Court Ltd DS0000013956.V288726.R01.S.doc Version 5.1 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 Ashridge Court Ltd DS0000013956.V288726.R01.S.doc Version 5.1 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): 1, 3 & 6 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. The home has good documentation in place to inform existing and potential new residents of the services offered. There are good processes in place for assessing potential new residents prior to admission with services being offered to only those residents whose needs can be met. EVIDENCE: It was evidenced that the current Statement of Purpose and Service users’ Guide is displayed within the home. Copies of the both documents were noted in the main reception area of the home and in each of the resident’s bedrooms that were viewed. Residents spoken with knew about these documents and said that they had received them prior to admission. The Registered Manager and Nursing staff reported that new documentation is in place, which allows for the recording of all aspects of Residents needs at the pre- admission assessment stage. Documentation relating to pre-admissions were viewed and it was noted that the document allows the assessor to gain thorough details of individuals medical, social and personal care needs.
Ashridge Court Ltd DS0000013956.V288726.R01.S.doc Version 5.1 Page 10 Intermediate care is not provided by this service. Ashridge Court Ltd DS0000013956.V288726.R01.S.doc Version 5.1 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 & 11 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. Residents are offered a good provision of health and personal care support by the home, with residents needs being met. EVIDENCE: Four residents were case tracked throughout the inspection process. From discussions with the Registered Manager, with nursing staff and from documentation viewed, it was evident that new ‘Standex’ recording tools had been obtained by the home and that such documentation had been incorporated into the care plans for current residents. The new recording tool allows for the assessment of residents health, personal and social care needs to be fully recorded and reviewed. It was also noted that details of any specialist interventions required e.g. for the management of nutrition, pressure area care and wound dressings are specified and recorded in residents care plans. The home has access to the specialist services of a Tissue Viability Nurse and Dietician. Nursing staff confirmed that these specialists attend the home both on a regular and an as required basis. Documented records viewed supported this.
Ashridge Court Ltd DS0000013956.V288726.R01.S.doc Version 5.1 Page 12 From the records sampled and from discussions with staff it was evidenced that the health needs of residents are well met with evidence of good multi disciplinary working taking place, on an as required basis. Staff said that residents have a choice of GP and can retain contact with professionals such as dentists and opticians whom they had visited before coming to the home. The home also utilises the services of a private Physiotherapist and Occupational Health Therapist. The home has good procedures in place for the monitoring and recording of all drugs entering and leaving the home and drugs being administered. Medication stores and dispensing facilities were viewed and it was evidenced that these were maintained in a clean an orderly manner. A good medication policy is in place and there was evidence of an annual review of this document by the Registered Manager. The home has recently had a Pharmacy Inspection conducted and it was pleasing to note that the issues raised during this inspection had been actioned by the home. Personal support in the home is offered in such a way as to promote and protect resident’s privacy and dignity, whilst promoting their independence. Residents who spoke with the inspector said that staff are kind, caring and treat them with respect at all times. The Registered Manager said that the home records residents wishes in the event of dying or critical illness, that residents wishes would be respected until such time that the home is unable to meet the needs of the resident and that family members of a dying resident could remain with them for as long as is necessary, in order to pay their respect. Residents acre files viewed supported this. Ashridge Court Ltd DS0000013956.V288726.R01.S.doc Version 5.1 Page 13 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 area is good. This judgement has been made using the available evidence including a visit to this service. The home provides good social, cultural and recreational facilities, including a balanced diet to residents and in accordance with their wishes. EVIDENCE: Residents said that they enjoyed many of the home’s activities and that the home staff were flexible in allowing residents to choose the level of activities attended. A published list of activities is made available to residents, with residents being informed of special events being held in the home’s three monthly newsletter. From the Service Users Surveys received three of the five respondents stated that they always liked the activities provided by the home, with two stating that the usually enjoyed them. Discussions with the Registered Manager highlighted that although the current residents fell into a specific age group and had similar religious beliefs, the home would welcome any potential new resident who has special cultural/religious/spiritual beliefs and would make provision to accommodate their needs. The home believes in promoting an equal and diverse culture among staff and residents. Resident’s family, friends and representatives are welcomed by the home. The Registered Provider said that many of the residents enjoy close contact with
Ashridge Court Ltd DS0000013956.V288726.R01.S.doc Version 5.1 Page 14 their families and friends. Residents are encouraged to remain independent and those who are able attend events, religious ceremonies and the local community at a level of their choosing. Assistance is given to those who are unable to attend the local community independently. Residents spoken with confirmed that they enjoy attending events that are external to the home and that they are assisted as required. The home is run to ensure that the resident’s are encouraged to maintain their independence in making choices and decisions relating to their daily living. Any information relating to resident choice or decision-making is recorded in the resident’s care plan. Respondents to the Service User Survey and the resident’s representative stated that they always feel listened to by staff. The home’s menus are devised as a four-week rolling programme. Residents may have guests to stay for a meal at any time. The home’s Cook said that medical or therapeutic diets are provided as needed. The menu’s viewed showed that there is a good variety of food and that the menu’s are varied. Alternatives are available for the residents if they do not wish to eat what is on the menu. Records viewed detailed where an alternative meal option had been taken. Mealtimes can be flexible dependent on the resident’s daily plans. Drinks and snacks are available at all times. Meal options viewed at the time of the inspection were attractively presented, in particular those meals that were pureed. Residents said that they are involved with menu planning and that they food provided was good, especially since the home’s new chef had arrived. Ashridge Court Ltd DS0000013956.V288726.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. Resident’s benefit from a robust and efficient complaints procedure, whilst the home’s procedures, processes and staff training should protect service users in the event of an allegation of abuse. EVIDENCE: The home has an established Complaints Procedure in place. Residents said that if they had any complaints then they knew that they could approach any member of staff of the home’s management team. The home has received one verbal complaint since the previous inspection. Records of all verbal complaints are recorded and these were made available for inspection. The CSCI have received no complaints, relating to the home, in the last twelve months. Criminal Record Bureau (CRB) checks have been carried out on all existing staff. Both CRB and Protection of Vulnerable Adult (POVA) checks are carried out on all new staff. The home has an up to date copy of the East Sussex County Council Multi-agency Procedures for the Protection of Vulnerable Adults. Staff have attended training in the Protection of Vulnerable adults within the last twelve months, records viewed confirmed this. It was evidenced that the home’s Adult Protection Policy has been amended to state that Social Services are now the lead agency and the relevant contact details have now been detailed in this policy. Ashridge Court Ltd DS0000013956.V288726.R01.S.doc Version 5.1 Page 16 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 area is good. This judgement has been made using the available evidence including a visit to this service. The home provides a good quality of accommodation for residents that is safe, well maintained, hygienic and odour free. EVIDENCE: The location and layout of the home are suitable for its stated purpose. The home is well maintained and all areas of the home, including parts of the garden, are accessible to service users. Parts of the garden are at the present time inaccessible to residents due to the new extension building works currently taking place. Current building works have not impacted on the daily routines of the existing home, residents and staff spoken with confirmed this. The home has an ongoing plan of refurbishment in place. It was evidenced during the inspection process that the home is currently in the process of obtaining new dining room and bedroom furniture. Residents spoken with said that they liked their bedrooms and that the communal areas of the home were comfortable and decorated nicely.
Ashridge Court Ltd DS0000013956.V288726.R01.S.doc Version 5.1 Page 17 The home was clean and odour free throughout. An effective infection control procedure is in operation in the home. The home has a clinical waste contract in place. The Registered Manager said that all staff are trained in infection control procedures. Staff spoken with were aware of infection control policies and procedures. Staff were observed adhering to the procedures and records viewed also confirmed this. Ashridge Court Ltd DS0000013956.V288726.R01.S.doc Version 5.1 Page 18 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 area is good. This judgement has been made using the available evidence including a visit to this service. The home has a suitable staff team with the necessary skills and experience to the meet the needs of current residents. EVIDENCE: A competent staff team, sufficient in number, meets the resident’s needs. There is a staff rota in place, which was made available to the inspector with the home’s pre-inspection questionnaire. Residents and relatives said that there are enough staff to meet their needs, or their relatives needs, and that staff are always helpful and pleasant. The Registered Manager said that the home has three care staff trained to National Vocational Qualification (NVQ) level two or above, with a further six staff undertaking an NVQ level two course. This was confirmed in the home’s Pre-Inspection Questionnaire and from staff training records viewed. Once those care staff who are undertaking the NVQ training have completed their course, the home will have met the target of the required 50 of trained members of care staff. Staff recruitment files were viewed and it was evidenced that not all files contain the items required under the Care Homes Regulations 2001. Items such as proof of identity, a recent photograph, evidence of relevant training and qualifications were noted as missing from some, but not all, of the staff
Ashridge Court Ltd DS0000013956.V288726.R01.S.doc Version 5.1 Page 19 files viewed. Of the files that were viewed those for newly recruited staff were well maintained, however those which had items missing were for staff that had been employed by the home for a long period of time, this was discussed with the Registered Manager who said that previous administrators who had worked at the home had ‘probably archived these documents’. Therefore a requirement has been made. The home has an Equal Opportunities policy in place and is an equal opportunities employer. A number of the current staff team are from Poland, Japan and China. All necessary visa and Home Office related documents were found to have been obtained and kept on file for these employees. Staff training records showed that over the last twelve months the home had provided a range of training, including Induction Training, Medication Training, Fire Training, Health and Safety, Food Hygiene, Moving & Handling, Infection Control and First Aid. Other training related to the needs of the resident’s such as Tissue Viability, Caring for the Patient With Dementia, Diabetes and Urinary Tract Infections has also been undertaken. Registered Nurses spoken with at the time of the inspection said that they felt the training provided was good and provided them with the opportunity to achieve their Post Registration Education and Practice (PREP) requirements, as governed by the Nursing & Midwifery Council (NMC). With some staff undertaking the Adaptation Training in nursing, which is provided by this home. The Registered Manager said that the home were currently in consultation with Greenwich University with regards to Common Induction Standards and that one staff member has completed two modules of the training course. Ashridge Court Ltd DS0000013956.V288726.R01.S.doc Version 5.1 Page 20 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, 37 & 38 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. The management and administration of the home is good, with evidence of consideration being given to residents choice and opinion with the health, safety and welfare of residents and staff being protected at all times. EVIDENCE: The Registered Manager has many years relevant experience in caring for older people and has obtained the Registered Managers Award and is a qualified Registered Nurse. Residents said that the Registered Manager was friendly and approachable and always willing to act upon issues raised. There is a Quality Assurance policy in place, that involves an annual development plan and continual self-monitoring of the home by the Organisation. Quality Assurance questionnaires were given to all service users and visitors to the home in August 2005, however the results of which have
Ashridge Court Ltd DS0000013956.V288726.R01.S.doc Version 5.1 Page 21 not been published and made available to all. This was discussed with the Registered Manager at the time of the inspection, who said that this would be completed within the next few weeks. The Registered Manager said that poor responses to previous questionnaires had been discussed with residents at the last Residents Meeting and it was reported that residents felt that they did not have to provide written responses as they deemed their verbal feedback as being sufficient. Residents Meeting are held six to eight weekly, the minutes of which are published and were noted to be located in a file in each resident’s bedroom. The home does not take any responsibility for resident’s finances. The home’s policies and procedures file was viewed and it was evidenced that all policies and procedures have been amended to provide the current contact details of the CSCI and that all policies and procedures have been adapted in order to make them specific to the home. The home’s maintenance files were viewed and it was evident that fire drills, fire alarm testing and fire equipment checks, water checks and Portable Appliance Testing (PAT) had been carried out. Accidents are well documented in the home’s accident book. Fridge, freezer and food temperature probe readings are recorded on a daily basis. There is a suitable risk assessment relating to the building works in place, this is maintained by the building contractor foreman who discusses any issues with the home’s Registered Manager on a daily basis. Ashridge Court Ltd DS0000013956.V288726.R01.S.doc Version 5.1 Page 22 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X 3 3 Ashridge Court Ltd DS0000013956.V288726.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP29 OP33 Regulation 19(1)(a) (i)& Sc2(1-6) 24 Requirement That recruitment files for all staff comply with the Care Homes Regulations 2001. All results of residents, relatives and visitors questionnaire surveys must be published and made available. This is outstanding from the previous inspection. Timescale for action 18/06/06 18/07/06 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 Ashridge Court Ltd DS0000013956.V288726.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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