Inspection on 05/12/06 for Ashtead House

This inspection was carried out on 5th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashtead House 11/07/07

Ashtead House 24/10/05

Ashtead House 06/06/05

Ashtead House 14/12/04

Ashtead House 20/09/04

Ashtead House 16/02/04

Similar services:

Thorndene

Sutton Lodge Nursing Home

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

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

CARE HOME ADULTS 18-65 Ashtead House Ashtead House 153 Barnett Wood Lane Ashtead Surrey KT21 2LR Lead Inspector Damian Griffiths Key Unannounced Inspection 5 December 2006 09:00 Ashtead House DS0000013561.V305141.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ashtead House DS0000013561.V305141.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ashtead House DS0000013561.V305141.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashtead House Address Ashtead House 153 Barnett Wood Lane Ashtead Surrey KT21 2LR 01372 810330 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) Ashtead House Ltd Miss Sheila Cassidy Care Home 10 Category(ies) of Learning disability (6), Physical disability (4) registration, with number of places Ashtead House DS0000013561.V305141.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be 18 - 60 YEARS. 24th October 2005 Date of last inspection Brief Description of the Service: Ashtead house is a detached property set in its own grounds a short distance from local shops of Ashtead town centre. Accommodation is situated on the ground floor and first floor. All bedrooms are single occupancy, five bedrooms on the first floor and five on ground floor. There is no lift to access the upper floor. One of the bedrooms on the ground floor is being used as a quiet room and contains the service users computer. There is a communal garden at the rear and parking for several cars at the front. The home is registered to ten people with mild to moderate learning disabilities and physical disabilities. Ashtead House DS0000013561.V305141.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of the Commission for Social Care Inspection (CSCI) year April 2006 to 2007 using the new ‘Inspecting for Better Lives’ (IBL) process. The Inspector would like to extend his appreciation to the Manager Sheila Cassidy representing the establishment who assisted Regulation Inspector Damian Griffiths throughout the morning of the inspection. The IBL process involves a pre-inspection assessment of service information from a variety of sources initially helping to prioritise the order of inspections and identify areas that require more attention during the inspection process. A new Inspection record is compiled from details received from a preinspection questionnaire, notifications of significant events known as Regulation 37’s compiled by the home. Any comments and complaints received and previous inspection reports are all considered for inclusion prior to the inspection visit. For more details of ‘IBL’ please visit the Commission for Social Care Website details can be found on the last page of this Inspection report. The inspector was with staff and service users at Ashtead House for a period of 6 hrs. The care needs of the service users at the home were complex and demanding and staff were required to be competent communicators. The inspector ensured that time was spent sampling service user’s care need assessments, care plans, talking to service users and observing interaction between service users and staff. Staff files were inspected for evidence of good practice in the following areas: recruitment, training and the distribution of staff skills compiled in the daily rota. Completed CSCI surveys were received from service users, relatives visitors and a social and care practitioner. A relative /visitor completing the SCSI survey stated: ‘An excellent home with caring staff’. The inspector would like to extend thanks to the residents, their relatives, management and staff at Ashtead House for their time and hospitality. What the service does well: All files sampled contained adequate assessment of need that had received regular review and the home enabled service users to fully participate within the local community. It supports service users to take appropriate risks by negotiation and demonstrated that it was providing the opportunity for greater independence and social mobility. Ashtead House DS0000013561.V305141.R01.S.doc Version 5.2 Page 6 Service users appreciated the opportunities and activities provided at the home and were able to make full use of the local community facilities available. Sensitivity was shown regarding service user relationships with family and friends who were always welcomed. Service users received the opportunity to choose their meals and were encouraged to participate with the cooking and shopping. Service users wishes were sought in order to ensure their health and emotional care needs were met. Service users were given every opportunity to use the complaints procedures that was available and in different written formats for better understanding and the home showed that it had full understanding of the issues regarding safeguarding vulnerable adults. Service users were actively helping to improve their home environment, which was clean and spacious providing a selection of rooms to relax or socialise in. Recruitment procedures at the home were good and the manager was supported well by the staff in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. Comments received from service users completing the CSCI survey, about ‘what’s good about living at your home’ said: ‘Because the home has a friendly environment’ ‘Friendly- I am getting help to be a little independent’ ‘I like living with everyone here’ ‘Every body is friendly and look after me’ What has improved since the last inspection? What they could do better: Three requirements were made: Ashtead House DS0000013561.V305141.R01.S.doc Version 5.2 Page 7 The home ensures that a system to review the quality of care offered by the home in consultation with the service users is completed with identifiable outcomes provided to all parties involved. The office attached to the home was in need of attention due to the poor quality of build and subsequent health and safety concerns and that the office is, so far as reasonably practical, free from hazards: That a system to review the quality of care offered by the home in consultation with the service users is completed with identifiable outcomes be provided to all parties involved. The following good practice recommendation was made: It was recommended that the home review its medication administration procedures and staff concerns when under pressure. 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. Ashtead House DS0000013561.V305141.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashtead House DS0000013561.V305141.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All files sampled contained adequate assessment of need that had received regular review. EVIDENCE: The assessments for two of the most recent service users were sampled and showed that comprehensive assessment of care need was in place. The home ensured that information about the home is available to prospective service users. A relative completing the CSCI survey stated that: ‘Service users X moved into the home some years ago and the beneficial affect on him has been startling’. Ashtead House DS0000013561.V305141.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6.7 and 9. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home enables service users to fully participate within the local community and supports service users to take appropriate risks by negotiation that was shown to provide greater independence and social mobility. EVIDENCE: Care plans (Lifestyle plan) sampled included a comprehensive assessment of need that incorporated all aspects of the service users life and in particular any difficulties requiring support, including health, personal care, behaviour modification and activities. Each care plan folder contained evidence of joint working with other health and social care practitioners and details of how to provide the care assessed. All agreements evidenced at the home indicated that service users had been consulted. This was a crucial aspect contributing to the success of any social contract for agreement to modify service users behaviour that was being managed. Service users were given responsibility to do their own chores, chose meals and evidenced the decisions about what Christmas decorations to buy. Each Ashtead House DS0000013561.V305141.R01.S.doc Version 5.2 Page 11 service user was encouraged to attain a safe level of independence using the risk assessment process. All service users consulted stated that they were involved with the monthly house meetings and were able to discuss their needs, likes, and problems. Correlation of the homes risk assessment process and details received about a service user incident included in the Regulation 37 sent by the home showed that guidelines were being appropriately followed. Other assessments were seen to be up-to-date and relevant to the service user need. One service user employed at the local leisure centre was being supported to take driving lessons. The code of conduct and privacy policy was available on one of the new service users files listing the promotion of a safe environment and respect for privacy with bullet points such as: ‘No entry to service users room unless invited’ and ‘all paper work relating to service users be completed in a private location’. There were also agreements about the individual requirements of new service users such as: ‘staff are not to wake’ the particular service user. A social care practitioner and visitor completing the SCSI survey agreed that: ‘staff demonstrated a clear understanding of their clients needs’. Ashtead House DS0000013561.V305141.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff. Service users appreciated the opportunities and activities provided at the home and were able to make full use of the local community facilities available. Opportunities to voice opinions and make choices were possible. Sensitivity was shown regarding service user relationships with family and friends who were always welcomed. Service users received the opportunity to choose their meals and were encouraged to participate with the cooking and shopping. EVIDENCE: One service user was supported to maintain a seasonal job and staff were helping him with a job application by e-mail. Service users were encouraged to try different routines in order to achieve tasks around the house such getting up at early to complete ‘paid’ housework tasks that may assist future employment outside of the home. Ashtead House DS0000013561.V305141.R01.S.doc Version 5.2 Page 13 Service users had full access to the local community, the town and local shops that were close by and service users who wished to go would be accompanied by staff of go on their own. Family friends and significant other were encouraged and supported to attend the home. Comments on the CSCI survey: included a service users stating that,’ I am getting help to become more independent’. Full details of family and friends were evidenced on files. If the family circumstances did not merit visits then the home would make special arrangements to be implemented. This has been done in preparation for the coming holidays and visits to attend the Pantomime and other activities had been arranged. Routines were respected and at time new routines were encouraged such as getting up at a different time to do chores and to take medication. The (Lifestyle plan) care plans included what help the service users needed. Service users would shop and were encouraged to cook or prepare snacks there was however a choice of two daily menus. Fresh fruit and vegetables were available each day. Service users consulted, all stated that meal’s were good and that they could chose what they liked to eat and that fresh vegetables were always included and a bowl of fruit was on the table. A visitor and therapist completing the CSCI survey agreed that: ‘the home communicated clearly and worked in partnership with them’. Ashtead House DS0000013561.V305141.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18.19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users wishes were sought in order to ensure their health and emotional care needs were met. Medication Administration was good but there was one minor area to be reviewed. EVIDENCE: Service users preferences about how they wished to be helped with personal care needs were respected and recorded. They have a ‘Health Action Plan’ that stipulated what help they will receive and how they prefer to receive it. Each service user had a record of ‘Medical Services Received’ document highlighting each health care service recently received. These were up to date and evidenced that regular health care needs were in order. Staff were observed responding to emotional outbursts from service users with calm and sensitivity. Medication at the home was appropriately secured. Medication Administration Records (MAR) showed that the morning medication had not been recorded. A check of the tablets contained in blister packs showed that the service users had received them. The staff member had Ashtead House DS0000013561.V305141.R01.S.doc Version 5.2 Page 15 attained a medical handling training certificate, however, it was evidenced that the staff member was under pressure at the home due to another staff member being off on sick leave. Drug returns book had been signed by the pharmacist and was all in order. It was recommended that another staff member check the medication in these circumstances. Please see the recommendations section of this report. Ashtead House DS0000013561.V305141.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were given every opportunity to use the complaints procedures that was available and in different written formats for better understanding. The home showed that it had full understanding of the issues regarding safeguarding vulnerable adults. EVIDENCE: Service users usually have the opportunity to complain at the monthly service users meetings held at the home. Evidence of complaints had been minuted in the service users meeting and showed that the subject was about the choice of food on the menu. The complaints procedures had been updated and there were copies of a pictorial account of how to complain available to service users. There was evidence to show that complaints were dealt with promptly however one service user felt that staff do not always sympathise or take their complaints seriously. A social care practitioner completing the CSCI survey and a relative/visitors agreed that: They were aware of the complaints procedure but had never needed to make a complaint. There had been occasions that the home had needed to activate the ‘Safeguarding of vulnerable adult’s procedures’ and evidence from Regulation 37 activity that the procedures were used properly and effectively and the management of an incident earlier this year had been commended by other Ashtead House DS0000013561.V305141.R01.S.doc Version 5.2 Page 17 parties involved. The home was able to show that it had all the necessary details of the procedures in place. The home has a restraints policy and practice in place but does not use actual physical restraint preferring instead to manage behaviours by negotiation and as a last resort, the Police. Service users completing the CSCI survey agreed that: staff cared for them well and that they felt safe. Ashtead House DS0000013561.V305141.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users were actively helping to improve their home environment, which was clean and spacious providing a selection of rooms to relax or socialise in. The office attached to the home however was in need of attention due to the poor quality of build and subsequent health and safety concerns. EVIDENCE: A tour of the premises was conducted and service users assisted and were consulted about it. The manager had sent regular Regulation 26 reports that included maintenance requirements that were listed in the report. These were confirmed during the inspection process; however, there remain some areas of concern that may not be rectified by the proposal stated in the report. The office continues to be a very poor environment to work in owing to being a mainly glazed room therefore it is cold in the winter and very hot in the summer. The maintenance report suggested that a false ceiling and air conditioning was required however the office was very small and this solution Ashtead House DS0000013561.V305141.R01.S.doc Version 5.2 Page 19 may not address the problem of limited space that continues to put staff at risk of accident or illness in its current condition. The service users had made a really good job of painting and decorating the main living room area. Maintenance personnel for the home was still in need of confirmation, therefore all maintainence about the home was currently being completed by personnel from another home within the organisation. A service user gave the inspector a tour around the laundry area and explained that a laundry rota was in place for the service users convenience and ease. The laundry area was in constant use but clean and reasonably tidy. Please see the requirement section of this report. Ashtead House DS0000013561.V305141.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34,and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff were trained to meet the needs of the service users and they were seen to respond well to their needs. Recruitment procedures at the home were good however, the managers office did pose some health and safety concerns. EVIDENCE: Staff training was inspected to ensure the skill of the staff team corresponded with the needs of the service users group. Staff had received a mixture of training and were well equipped to help and assist service users. Training included: Fire safety awareness, health and safety, first aid, manual handling, safe administration of medication, Bereavement awareness, risk assessment, makaton, epilepsy, conflict management. All staff had received training in the safeguarding of vulnerable adults in accordance with the Surrey multi-agency procedures. An organisation used for assisting staff with the challenging behaviour of the service users also provided the staff team with valuable training in areas of conflict management and ‘diffusing situations’. Three staff files were sampled for evidence of good recruitment procedures. This included new staff at the home. Documentation such as: references employment history and criminal record checks were in place. Ashtead House DS0000013561.V305141.R01.S.doc Version 5.2 Page 21 A social care practitioner completing the CSCI survey agreed that: ‘there was always a senior staff member available to speak to’ and that ‘home always notified them of significant events’. Ashtead House DS0000013561.V305141.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager was supported well by the staff in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. The health and safety of the service users was good however the manager’s office would pose some health and safety concerns if proposals do not materialise. EVIDENCE: Staff and service users consulted where pleased with the management approach and style and it was established that the manager was well respected and staff were seen to support her in applying a consistent approach. The service users consulted confirmed that they do have regular ‘house’ meetings; however, there was no evidence of any minutes being taken of these meetings from July to November this year. It was observed that the service users were able to discuss their views with staff throughout the Ashtead House DS0000013561.V305141.R01.S.doc Version 5.2 Page 23 inspection and were happy to take responsibility for a variety of tasks including putting up the Christmas decorations and lights. The organisation has a quality assurance officer to oversee this and other areas of service user care and the regulations 26 notifications come with quality review report attached however this had yet to be completed. The overall quality of communication was very good. Daily Health and safety checks to service users rooms were conducted by staff and all daily requirements to promote and protect the health and safety of staff and service users was observed on the day of the inspection. Hot water and refrigeration temperatures were correct; COSHH procedures and safety were in measures in place. Fire drills and fire extinguishers were all in order, and fire drills recorded. Details of how health and safety is to be assured and adequate space is to be provided in the office must be submitted to CSCI. Please see the requirement section of this report. Ashtead House DS0000013561.V305141.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 2 X X 2 X Ashtead House DS0000013561.V305141.R01.S.doc Version 5.2 Page 25 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA24 Regulation 13(4)(a) Requirement Timescale for action 05/02/07 2. YA39 3. YA42 The registered person must ensure that the office is, so far as possible, free from hazards to the safety of staff and service users by completing the proposed improvements as soon as possible. 24 The registered person must ensure that a system to review the quality of care offered by the home in consultation with the service users is completed with identifiable outcomes to be provided to all parties involved. 13(4) The registered person must 23(1)(a)(2)(a) ensure that all parts of the (4)(iii) home, including the office that are assessable to the service users are free from hazards: the premises are suitable for the purpose of achieving the aims and objectives set out in the statement of purpose. 05/02/07 05/02/07 Ashtead House DS0000013561.V305141.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. Refer to Standard YA20 Good Practice Recommendations It was recommended that the home review its medication administration procedures and staff concerns when under pressure. Ashtead House DS0000013561.V305141.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Ashtead House DS0000013561.V305141.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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