Inspection on 20/07/06 for Ashridge House

This inspection was carried out on 20th July 2006.

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

Other inspections for this house

Ashridge House 08/04/10

Ashridge House 29/04/08

Ashridge House 17/12/07

Ashridge House 23/05/07

Ashridge House 09/12/05

Ashridge House 23/06/05

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 Ashridge House 132 Dorset Road Bexhill-on-sea East Sussex TN40 2HT Lead Inspector Melanie Freeman Key Unannounced Inspection 20th July 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ashridge House DS0000062830.V303071.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. Ashridge House DS0000062830.V303071.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashridge House Address 132 Dorset Road Bexhill-on-sea East Sussex TN40 2HT 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 222200 Sarojini Sivayogarajah Vacant Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Ashridge House DS0000062830.V303071.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users that can be accommodated is twenty nine (29). Service users must be older people aged sixty five (65) years or older on admission. That one named service user under the aged of sixty five (65) can be cared for in the home. 9th December 2005 Date of last inspection Brief Description of the Service: Ashridge House is registered to accommodate up to 29 older people in receipt of personal care, the registered provider is Mrs Sivayogarajah. Ashridge House is a large detached property situated on the outskirts of Bexhill on Sea. The town centre with its shops and access to bus and rail routes is approximately a mile and a local shopping centre is approximately half a mile. Accommodation is provided on three floors and a shaft lift is fitted to assist those service users who may have mobility problems. Bedroom accommodation is provided in 25 single and two double rooms. The home provides care and support to residents who are both privately funded and those who are funded by Social Services. The home’s fees as from 01 July 2006 range between £322.40-£450.00 per person per week depending on the room to be occupied and the care needs of the individual. Additional costs are charged for chiropody (approx £10) hairdressing, newspapers and magazines. The homes literature states that the objective of the home is that residents shall live in a clean, comfortable and safe environment and be treated with respect and sensitivity to their individual needs and abilities. Ashridge House DS0000062830.V303071.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Ashridge House will be referred to as ‘residents’. This was a key inspection that included an unannounced visit to the home and follow up contact with resident’s representatives and visiting health and social care professionals. The unannounced visit included a meeting with the registered manager who facilitated the inspection process and received the inspector’s feedback at the end of the inspection. On the day of the home visit the inspector spent most of her time meeting with residents and their visitors, and observing practice in the home. A tour of the premises was undertaken and a range of documentation was reviewed including the homes statement of purpose and service users guide, care plans, duty rotas, medication records, and recruitment files. The care documentation pertaining to three residents was reviewed in depth along with a number of policies and procedures and records relating to health and safety. The inspector was able to eat a midday meal with the residents in the communal dining room during the unannounced visit. In addition service users surveys were given to 10 residents or their representatives and 4 staff surveys were left in the home for identified staff to return. The information contained in the returned surveys has been incorporated into this report. What the service does well: The staff and management of the home are welcoming to all visitors and this positive approach was commented on by all people spoken to about the service. Residents and a visitor spoken to spoke very positively of the care provided by the manager and her staff team and care observed during the inspection was good and appropriate. The meals provided are excellent and all residents complimented the food and choices available. The acting home manager has an approachable manner and is responsive to residents, visitors and staff views. Ashridge House DS0000062830.V303071.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Full and comprehensive information on the home and services it provides must be available to all interested parties to inform any prospective residents choices. The care documentation including preadmission assessments and care plans were found to be of a poor quality and need to be improved to ensure residents receive appropriate care that meets their assessed needs. Further attention needs to be given to providing appropriate entertainment and activities to ensure individual recreational and leisure needs of residents are met. The procedure for investigating complaints needs to be improved to ensure effective resolution. Staff need to have a clear understanding of adult protection issues and have a clear procedure to follow in the event of abuse being alleged or suspected to ensure residents safety. Suitable staffing arrangements need to be adopted to ensure staff are able to fulfil their identified roles effectively. Staff have been allowed to work in the home without having the appropriate checks completed, staff should only be employed subject to POVA/CRB checks being completed as necessary to ensure residents are safeguarded. A registered manager has still not been appointed and this must be addressed to ensure an appropriate management structure in the home. Quality assurance measures that respond to resident’s views need to be established and reported on. All health and safety systems need to be maintained and updated including the necessary environmental risk assessments that address the accessibility of hot water to residents. Ashridge House DS0000062830.V303071.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ashridge House DS0000062830.V303071.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashridge House DS0000062830.V303071.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are not provided with full and accurate information about the home to inform their choice of home. All residents are assessed prior to admission and residents are only admitted to the home if their needs can be met. EVIDENCE: During the inspection visit it was noted that the registration certificate was not fully displayed in a prominent position and the information contained within the statement of purpose was not up to date or accurate. In addition the inspection report displayed was not the most recent. These shortfalls were discussed with the home manager. A review of the care documentation confirmed that pre-admission assessments are completed by the acting home manager prior to an admission being agreed and ensures that the needs of residents admitted to the home can be met by Ashridge House DS0000062830.V303071.R01.S.doc Version 5.2 Page 10 the staff within the homes environment. The last two pre-admission assessments were reviewed to assess the quality of these assessments. They were found to be rather limited and did not reflect a multi disciplinary approach to care, some documents were also not dated or signed. During the site visit the inspector observed that a prospective resident was able to visit the home with her relatives and was given the opportunity to spend time in the home and offered lunch. Intermediate or rehabilitative care is not provided at Ashridge House Care Home. Ashridge House DS0000062830.V303071.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all residents have an individual plan of care and those provided do not set out the action to be taken by care staff to meet all aspects of the residents care. However resident’s health and personal care needs on the whole are met whilst respecting their privacy. Procedures and practice in the home allow for the safe administration of medicines. EVIDENCE: The care documentation pertaining to 3 residents was reviewed as part of the inspection process and each of these residents were met with during the inspection visit to the home. Although it was noted that the care needs of these residents were being responded to the care documentation was found to be very poor. One resident did not have a plan of care at all and her assessment of need was limited. Ashridge House DS0000062830.V303071.R01.S.doc Version 5.2 Page 12 A further resident with dementia type illness had no reference to how the specialist care needs of this residents were to be met, it was noted that she ate alone but why this was the case was not recorded in the plan of care. The basic care needs of another resident were recorded however there was no reference to the care needs that initiated his admission to residential care and those that needed close monitoring. All residents spoken to were very happy with the care and support provided to them and this view was echoed within the surveys received. Relatives contacted also spoke highly of the staff and comments made included; ‘staff look after her with respect and meet her personal and hygiene needs’ , ‘staff are kind and never make one feel a nuisance, bells are answered promptly’, ‘I could not have believe that I could have given up my home and moved to one room and been so happy with it and the care I receive’. One relative however did feel that some further attention was needed in respect to the personal care provided and the acting home manager has agreed that further input from the care staff is now needed. Medicine practice was found to be appropriate with clear and accurate records being maintained in the home. However it was noted that the key was not stored securely and this was raised with the acting home manager to address as a priority. One resident self-administers and a risk assessment has been completed. Good practice was noted in respect of the home involving other health care professionals and an example of this was the involvement and working with the continence advisor, respiratory specialist nurse and a nurse who reviews medicines. Staff were found to be respectful towards residents and visitors. Both visiting professionals and relatives confirmed that they are treated very well when attending the home one saying that she was ‘welcomed with open arms’. Promotion of independence and choice was noted and one resident had been able to bring in her own electric chair to promote her independence. Ashridge House DS0000062830.V303071.R01.S.doc Version 5.2 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 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are able to make a range of choices about their lives as well as maintaining links with friends and relatives. The arrangements for recreation and stimulation in the home are limited. Meals provided for residents are excellent allowing for individual choice and balanced meals. EVIDENCE: Staff have made efforts to ensure that residents who are able to enjoy mixing with other residents are facilitated in this process, residents clearly enjoy this interaction and meal times are a social event. Relationships between residents and staff are good and contribute to a feeling of well-being. Those residents able to leave the home unaccompanied are encouraged to do so and to maintain links with the community. Some entertainment is provided but the level of stimulation in the home is limited. Ashridge House DS0000062830.V303071.R01.S.doc Version 5.2 Page 14 The acting home manager confirmed that activities and entertainment has not been her priority but will be looking for someone with particular skills in this area to facilitate further progress to include trips and outings from the home. The meal eaten was very good and very much enjoyed by all residents, choices were given and all residents complimented the food greatly saying ‘the food here is excellent’. The cook works in the home every day and there is always a cooked main course and a cooked evening meal. A glass of wine is also provided with the Sunday dinner if wanted. Residents spoke about how they kept contact with their relatives and how important this contact is. Residents use the telephone and the computer to facilitate contact. Visitors are encouraged and staff promote residents choice and autonomy with all them able to choose where they spend their time. One resident does not have an identified representative and the use of advocacy was discussed with the acting home manager for her to progress in respect of this individual. Ashridge House DS0000062830.V303071.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems are not in place to ensure complaints are dealt with in an effective professional manner. Procedures and training in the home do not ensure residents are safeguarded against all forms of abuse. EVIDENCE: A full complaints procedure is in place however this should include the right of referral directly to the registered owner. It was also noted that complaints were recorded in a book available in a communal staff area therefore accessible to all staff members. A review of the complaint records identified that the registered owner dealt with the last complaint investigated, and its conclusion resulted in her giving a written warning to a staff member. Evidence of this warning was not however available within the individuals personnel file. Contact with the registered owner following the inspection confirmed that a written warning was not in fact given and the complaint was resolved without the need for this. The Complaints procedure needs to be reviewed to ensure appropriate action in response to any complaint raised and confidential record keeping at all times. The Adult Protection procedure is still not correct and does not demonstrate the correct procedures in accordance with the local guidelines. This needs to be updated and clearly identify the need to report to Social Services as the Ashridge House DS0000062830.V303071.R01.S.doc Version 5.2 Page 16 lead authority as necessary. Staff also need to be provided with the appropriate associated training as this was found to be lacking. Ashridge House DS0000062830.V303071.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24 and 26 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Residents live in an attractive home like environment that is well maintained and clean in most areas. Ashridge House promotes safe and individualised rooms with suitable facilities to meet resident’s needs. EVIDENCE: Ashridge House is a converted property that provides a home like environment. Redecoration and improvements to the environment have continued. Residents have the use of one large lounge/dining room; furnishings here are domestic in style, in addition there is a ground floor smoking area for residents. During the inspection visit residents were found to be using the garden and patio area, which provides an attractive outside area. Accommodation is on four floors and a shaft lift is fitted to assist those residents who may have mobility problems to access all areas. Sufficient bathrooms and WCs are available for the residents living in the home currently Ashridge House DS0000062830.V303071.R01.S.doc Version 5.2 Page 18 however the occupancy of the home is increasing and the bathing facilities will need to be improved as this continues to ensure appropriate provision to meet the needs of residents. The provision of an assisted shower was discussed with the acting home manager. A tour of the home confirmed a satisfactory level of cleanliness throughout although some further general cleaning was needed and these areas included dusting and vacuuming in some rooms. Resident’s rooms were found to be very personalised and individual with many having the resident’s own furniture. The laundry room also incorporates the sluice facility, and on the day of this visit the laundry room was found to be clean and tidy. However the clinical waste bin stand was found to be rusty and therefore could not be cleaned properly and needs to be replaced. Ashridge House DS0000062830.V303071.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents are having their needs met by suitably trained staff although staff are having to complete extra shifts and duties. The recruitment practice was found to be poor as it did not ensure all the necessary checks are completed before an individual starts working in the home. EVIDENCE: At the time of this inspection 17 residents were living at Ashridge House. The staffing arrangements provide two care staff during the day, in addition the acting home manager is able to work as a manager for two days a week on all other days she works as one of the carers. This does not provide time for individualised care or for the management of the home. The acting manager confirmed there had been some recruitment problems that have resulted in staff doing extra shifts and duties within these shifts. Two care staff spoken to said that they did not feel that two carers working in the morning was enough to meet the needs of residents especially as they were having to complete other duties like cleaning and laundry. Ashridge House DS0000062830.V303071.R01.S.doc Version 5.2 Page 20 During the inspection visit it was not identified that residents were not receiving the necessary care however it was clear that staff were being stretched and finding completing all the care and other duties stressful. Contact with staff confirmed that staff training is well promoted with staff able to attend all the necessary training. The acting manager said that half the care staff have now completed the necessary NVQ training. Individual personal development plans however are still to be provided. The recruitment files pertaining to the two most recently employed carers were reviewed as part of the inspection process and identified that one carer was working without any of the necessary paperwork being completed, no references had been requested and a POVA and CRB check had not been completed by the home. It was also noted that a volunteer was working in the home without any recruitment procedure being followed. An immediate feedback form was left in the home with the acting home manager to require that the home do not have people working in the home without the necessary checks being completed. The inspector also spoke to the homeowner when these shortfalls were identified and she confirmed that the carer would not be working in the home until the necessary checks had been completed and that she would cover her shifts herself. The acting home manager confirmed that the volunteer would not work in the home until recruitment procedures had been followed. Ashridge House DS0000062830.V303071.R01.S.doc Version 5.2 Page 21 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 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was found to be managed in an open and friendly manner although a stable management structure needs to be established. Systems to monitor and demonstrate the quality of care provided need to be fully established. Resident’s financial interests are safeguarded. The health, safety and welfare of residents and staff are generally promoted and protected although further attention is needed in respect to the accessibility of hot water. EVIDENCE: The acting home manager has applied for registration; her application for registration was however returned to her, as there was no accompanying required fee. Contact with the homeowner confirmed that there had been Ashridge House DS0000062830.V303071.R01.S.doc Version 5.2 Page 22 some discussions around the appointment of the current acting manager and this is why the registration has not been progressed. The homeowner was advised that she must appoint a suitably qualified and competent manager as a priority and that they must be registered by the CSCI. It was clear at the inspection visit that the acting manager was being overstretched and therefore not able to fully manage the home. It is vital that she receives the necessary support from the homeowner and that appropriate staff are employed in the home to allow her to fulfil her management role fully. The home has systems in place to monitor the quality of care in the home, which includes resident/visitors questionnaires and regular residents meetings. The feedback provided via these is mostly very positive and any comments are responded to on an individual basis, there is however no audit or report generated that could be included in the service users guide and provided to the CSCI and some of this quality monitoring work has been neglected recently due to staffing problems. The systems in place for the safe guarding of residents monies held by the home are robust and were found to include accurate records and appropriate receipt keeping. Records relating to Health and Safety in the home were reviewed and on the whole were found to be full and extensive. According to the home records some areas of the home accessible to residents indicated that hot water around 50 degrees C was being provided. This was identified within an immediate feedback form left with the acting home manager requiring her to risk assess and control the hot water of concern within one week. It was also noted that although thorough environmental risk assessments are completed this did not include the garden area. Ashridge House DS0000062830.V303071.R01.S.doc Version 5.2 Page 23 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 2 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 2 3 3 3 X X 3 X 2 STAFFING Standard No Score 27 2 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Ashridge House DS0000062830.V303071.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 and 5 Requirement That the registered person ensures that an up to date accurate statement of purpose and service users guide is available to all interested parties. That the pre-admission assessments are full, comprehensive and identify who has completed these and when. That each resident has a written care plan that records residents health, personal and social care needs. That plans of care are drawn up in consultation with residents or their representatives as appropriate and are reviewed regularly. (Outstanding from last inspection) That resident’s social interests are further assessed and an improved facility in respect to resident’s entertainment, activities and contact with the community is provided. (Outstanding from last inspection) That the registered person ensures that a full complaints procedure is used and that DS0000062830.V303071.R01.S.doc Timescale for action 01/09/06 2. OP3 14 01/09/06 3. OP7 15(1) 01/09/06 4. OP12 16 (m)(n) 01/09/06 5. OP16 22 01/09/06 Ashridge House Version 5.2 Page 25 6. 7. OP18 OP21 13(6) 23(2)j 8. OP26 16(2) 9. OP27 10 10. OP29 19(1) 11. OP31 8(1)(2) 12. 13. OP33 OP38 24 13 complaints are dealt with effectively. That the adult protection procedure is updated and further staff training is provided. That the bathing facilities in the home are kept under review to ensure suitability for residents living in the home. That the cleaning is improved to ensure a high standard of cleanliness throughout the home. That the rusty clinical waste stand is replaced. That appropriate numbers of staff are deployed in the home to enable staff to discharge their roles effectively. That the registered person operates a thorough recruitment procedure that includes the appropriate checks being completed before any person is deployed to work in the home. That the registered owner appoints a registered manager and provides them with the staff and support to discharge their responsibilities fully. (Outstanding from last inspection) That an effective quality assurance system is established and reported on. That generic risk assessments are used to ensure resident’s safety. These should include risks presented by the garden and hot water with appropriate control measures being taken. 01/10/06 01/09/06 01/09/06 01/09/06 01/08/06 01/10/06 01/11/06 01/08/06 Ashridge House DS0000062830.V303071.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP1 OP26 Good Practice Recommendations That the last inspection report is readily available to any interested party. That the sluice facility is separated from the laundry room. Ashridge House DS0000062830.V303071.R01.S.doc Version 5.2 Page 27 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 © 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 Ashridge House DS0000062830.V303071.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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