Inspection on 24/07/06 for Ashton Court

This inspection was carried out on 24th July 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ashton Court 24/05/07

Ashton Court 25/01/06

Ashton Court 03/08/05

Ashton Court 17/01/05

Ashton Court 16/06/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Ashton Court 376 West Road Newcastle Upon Tyne Tyne & Wear NE4 9RJ Lead Inspector Deborah Haugh Key Unannounced Inspection 24th July 2006 09:30 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 Ashton Court DS0000000392.V295154.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. Ashton Court DS0000000392.V295154.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashton Court Address 376 West Road Newcastle Upon Tyne Tyne & Wear NE4 9RJ 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) 0191 275 0638 0191 2750638 Solehawk Limited Mrs Sue Horsley Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places Ashton Court DS0000000392.V295154.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th January 2006 Brief Description of the Service: Ashton Court is a care home that provides personal care for 37 older people. The home is situated on the corner of the West Road and Two Ball Lonnen and is close to local amenities and public transport. There is an accessible garden and car parking space. Accommodation is over two floors and a passenger lift is provided. All bedrooms are currently single occupancy and there are larger rooms that can be used as doubles. The home has a large lounge that is divided into smaller areas and there is an adjoining dining room. The current fees charged per week are between £355 and £362. Ashton Court DS0000000392.V295154.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The un-announced inspection took place on 24/07/06 from 9.30am until 4.15pm. There were 21 residents living at the home. The home’s Registered Manager Sue Horsley was on duty during the visit. Time was spent looking around the home to check the cleanliness, maintenance and decoration during the visit. Time was also spent observing the contact between the residents and staff. Visitors were seen to freely come and go. Residents completed nine questionnaires. Relatives/visitors completed nine questionnaires. Residents and staff were spoken with. Two Care Plans were examined. Arrangements for the administration and management of medication were checked. Health and safety arrangements were examined as well as the catering, recruitment, protection of vulnerable adults (POVA) residents finances, fire instruction, training and complaints. What the service does well: Some of the residents shared their views of the home and these included. - ‘ It’s a nice home.’ - ‘ It’s a happy home, I enjoy playing dominoes.’ - ‘If I don’t like the food they always find me an alternative.’ - ‘As soon as I saw this home I wanted to stay.’ - ‘ I know I can be a nuisance sometimes but everyone is patient with me and always willing to help.’ - ‘All the staff are really nice. They talk to me and give me assistance.’ - ‘I have the same doctor I had at home. I haven’t needed to see him since I moved in, because I think I am being so well looked after.’ - ‘I am a member of the Dominoes Club and I like that best. I have been out on trips a couple of times. We have had some good parties.’ - ‘Lovely food.’ ‘We get plenty.’ - ‘The cleaners are nice cheerful girls always on the go.’ - ‘I am very happy. I didn’t think I would be … I look ten years younger since I came here.’ - ‘I find Sue and all the staff very helpful and friendly. Also a warm and happy atmosphere.’ Ashton Court DS0000000392.V295154.R01.S.doc Version 5.2 Page 6 Seven questionnaires from visitors said that they were satisfied with the overall care provided in the home. Visitors made the following comments - ‘Staff are very friendly, they work as a team.’ - ‘There’s always a lovely spread when we have a party. Bedrooms are personalised and people are encouraged to bring their own possessions and keepsakes. Catering arrangements. Staff are enthusiastic and 60 are trained to at least NVQ Level 2 in care. What has improved since the last inspection? What they could do better: The Registered Provider must ensure that outstanding requirements regarding the premises are completed which include The work on the upstairs shower room (bathroom 5) must be completed and made operational. Mildew to tiles in shower room 2 must be removed Odour from drains in bathroom 5 must be eliminated. Suitable ventilation must be fitted in the designated smoking room. The following new requirements must also be completed in relation to the premises, health and safety records, medication, references, and POVA first Ashton Court DS0000000392.V295154.R01.S.doc Version 5.2 Page 7 check and Criminal Records clearance for recruited staff. Care plans action to meet residents needs must be must be specific. Unannounced monthly visits and reports by the Registered Providers representative must take place and reports sent to CSCI each month. The Registered Provider must introduce quality assurance systems. 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. Ashton Court DS0000000392.V295154.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 Ashton Court DS0000000392.V295154.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): 3 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The home ensures that it can meet the needs of the service users as their needs are assessed prior to admission. EVIDENCE: Two residents records were examined and people are only admitted after assessments are received from placing authorities and/or the home has completed their own. Residents and relatives commented on their pre-admission and admission to the home. - ‘ I came to visit on a couple of occasions and was given leaflets and a booklet. I looked at all the photos around and decided it was good enough for me.’ -‘As soon as I walked in I felt comfortable.’ Ashton Court DS0000000392.V295154.R01.S.doc Version 5.2 Page 10 A resident was admitted during the inspection. The bedroom was already prepared with personal possessions and keepsakes before admission. The manager and her team ensured that the new person was seated with other residents at lunchtime and was happy with the lunch provided. During the afternoon the new person was invited to join in a game of Bingo. Staff introduced the new person to all the people playing Bingo. The new person said that they felt comfortable and made welcome. Ashton Court DS0000000392.V295154.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): 7-10 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Residents’ social and health care needs are regularly assessed, care planned and reviewed. Residents are protected by the home’s medication recording system but one area must improve. There are practices to make sure resident privacy and dignity is maintained. EVIDENCE: Resident care records demonstrated thorough assessment of needs, up to date care plans and individual care reviews. Residents or their representative involvement in reviews is evident. Evaluations are completed each month. Two entries in the care plans examined state ‘regularly’ and ‘offer foods which x liked.’ Actions to meet resident’s needs should be more specific. Ashton Court DS0000000392.V295154.R01.S.doc Version 5.2 Page 12 Residents have access to a wide range of health and social professionals. The staff are vigilant to changing needs and referrals are made for specialist professionals. Comments from residents regarding their healthcare included; - ‘ I have my own doctor and optician. The dentist, nurse and chiropodist visits.’ - ‘I have the same doctor I had at home. I haven’t needed to see him since I moved in, because I think I am being so well looked after.’ The home’s medication recording system was examined. Administration records were well recorded with no gaps to signatures and codes entered to state any reasons why medication is not given. The register for Controlled Drugs was also appropriately recorded. All care staff have completed medication training. Ointments are not included on Medication Administration Records. The Primary Care Team have recently completed a medication audit in the home. Personal care and medical examination/treatment is carried out in private. Staff check and record how residents prefer to be addressed and their preference for gender of carer. A pay telephone is available. Some residents have their own telephones in bedrooms. Mail is given unopened and staff/relatives support residents in dealing with correspondence. Systems are in place to make sure that residents wear their own clothes. All clothing is labelled and each resident has a named laundry basket. No bedrooms are shared at present. Residents spoken with confirmed that staff treat them with respect and maintain privacy and dignity. Ashton Court DS0000000392.V295154.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): 12-15 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Residents have access to activities, which they enjoy. Residents are given choices and encouraged to make decisions in daily living. Residents are able to maintain contacts with family and friends. Residents are provided with a variety and choice of meals. EVIDENCE: The home employs an activity co-ordinator for 15 hours a week. A volunteer comes in to the home 3 times a week to support the Domino club. Visitors also help with activities. During the morning the Domino Club was in full flow. People were clearly enjoying themselves. During the afternoon a friendly game of bingo occurred with staff help. Residents spoke of parties and trips, which they have enjoyed. People also shared other views - ‘ There are activities but I don’t usually join in.’ - ‘ There could be more outings.’ - ‘ They organise outings but then no one wants to go.’ Ashton Court DS0000000392.V295154.R01.S.doc Version 5.2 Page 14 The activities co-coordinator holds monthly meetings to discuss activities. Activities include cooking, reminiscence, pampering, theme days, and arts and crafts. People are able to order a newspaper. Some people knit squares for charity others like to listen to music or read. Residents are encouraged to manage their personal finances for as long as they have capacity to do so. Relatives and solicitors assist where needed. No one from the home/company has Appointeeship responsibility for any resident’s finances. Advocacy information is available. In practice many residents have relatives who advocate on their behalf. The extent of personal possessions that can be brought into the home is agreed before admission. Residents and relatives have access to personal records, and are involved in providing assessment information, care planning and reviews. A 4-week seasonal menu is in place with good variety and choice of meals. Breakfast consists of grapefruit, prunes, cereals, porridge, toast and cooked items daily. Lunch is a choice of main meal and dessert. On the day of the inspection the lunch meal was home made corned beef pie or sausage and onion casserole with carrot, turnip, broccoli with new potatoes. The dessert was apple pie and cream, stewed apple and custard or pears and cream. Tea consisted of salad, beef or sardine sandwiches, scones and jam tarts. Snack suppers are served with milky drinks. Preference sheets are completed daily indicating each resident’s choice of meals. Residents spoken with said the food was very good and there was plenty provided. - The food is nice and tasty. The cook knows how I like things so I have no complaints.’ Nutritional assessment is completed and care plans are devised where needed. Resident weights are monitored. Supplement drinks are home made with fruit, cream, ice cream etc. Care and catering staff are knowledgeable about nutritional needs of older people and fortifying foods to meet the nutritional needs of older people. Two residents currently require some assistance with feeding and staff sat with them. Two residents use plate-guards, one has adapted cutlery and ‘feeding’ cups are used at night to prevent spillage. The lunchtime meal was relaxed and unhurried. Ashton Court DS0000000392.V295154.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 & 18 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The home deals appropriately with complaints. There are procedures to protect residents from abuse. EVIDENCE: There have been no complaints since the last inspection in January. Staff know what to do should they receive a complaint from a resident or visitor. Nine service user questionnaires said that they knew who to speak to if they were unhappy. Nine questionnaires from visitors confirmed that they know how to make a complaint. Comments from residents and relatives included; - ‘I would speak to anyone, if I needed to I would speak to the Matron.’ - ‘ I have a notice in my room but I have never needed it.’ -‘I can speak to anyone, but I am happy. If I was not I would see Sue the boss.’ The home has policies and procedures for the protection of vulnerable adults, prevention of abuse and whistle blowing (informing on bad practice). Staff were able to describe in practice the Whistle Blowing Policy. Staff are provided with relevant training. There have been no allegations of abuse. Ashton Court DS0000000392.V295154.R01.S.doc Version 5.2 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, 21, 25 & 26 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. A number of improvements are still needed to the building. The home is kept clean and there are measures to control infection however the kitchen skirting board requires repair. EVIDENCE: At the last inspection there was a number of outstanding Requirements concerning improvements to the building. Further Requirements were also made. These were checked during a tour of the home. The following issues had not been addressed: - The work on the upstairs shower room must be completed and made operational. - Suitable ventilation must be fitted in the designated smoking room Ashton Court DS0000000392.V295154.R01.S.doc Version 5.2 Page 17 - During the tour the following issues were also noted: - Mildew to tiles in shower room 2 - Bedroom doors in need of repainting - Odour from drains in bathroom 5 (unused). - The flooring in bedroom 8 and 28 must be replaced and it is recommended that the flooring in bedroom 25 be also replaced. - Repairs to the dining room must be completed. - The exterior ‘Nursing’ signage at the front of building must be removed, as the home does not provide nursing care. - Repair bath top cover in bathroom 4. Resident bedrooms were nicely personalised with their belongings. The building was warm and clean. There are policies and procedures on infection control. Suitable hand washing facilities are provided in toilets, bathrooms, sluice, laundry and kitchen for staff hand washing. Disposable aprons and gloves are provided. The Manager is the link person for Infection Control and attends training/advice sessions. A senior carer is due to undertake training with the Infection Control Nurse and take on this role from the Manager. The skirting boards in the kitchen are loose behind the dishwasher and near the refrigerators, which compromises cleaning, and hygiene and must be repaired. This requirement was also identified in the Environmental Health Officers Report 10/01/06 and remained outstanding. Ashton Court DS0000000392.V295154.R01.S.doc Version 5.2 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): 27-30 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. There are good staffing levels to meet the needs of the number of residents. The recruitment process for new staff must improve. Staff are provided with a range of training relevant to their work with older people, including care qualifications but a training matrix must be provided to CSCI. EVIDENCE: At the time of the inspection there was 21 residents. There is suitable care staffing levels of 4 carers in the morning, 3 carers in the afternoons and evening and 2 carers at night. A part time Activities co-ordinator is employed. Weekly catering, domestic and laundry staffing hours were satisfactory. There were no current vacancies. Comments from residents and relatives included - ‘ There is always someone around.’ - ‘ Everyone is always nice and helpful.’ - ‘I am often unsettled at night. The staff talk to me and bring me drinks and sandwiches and I know they should sometimes be doing other things.’ Ashton Court DS0000000392.V295154.R01.S.doc Version 5.2 Page 19 Three new carers had been appointed since the last inspection. Staff recruitment records were examined. One record only had 1 reference when two are required. A member of staff has commenced employment without a Pova First check or CRB clearance. Staff in this situation must not commence work until a POVA check is obtained then they must be supervised and accompanied by a staff member who is appropriately qualified and experienced until CRB clearance is received. New staff complete induction training. Details of all training courses and certificates were not up to date. But staff confirmed recent training, which included safe working practices – fire safety, food hygiene, and moving and handling, and advanced first aid. Staff had also attended training on diabetes, continence, medication, blind awareness and palliative care. Care staff have either completed NVQ qualifications or are in the process of studying. Ashton Court DS0000000392.V295154.R01.S.doc Version 5.2 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 & 38 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. The home has a well-experienced Manager who provides clear leadership. Quality assurance systems are not in place to ensure that residents receive the service they want The home ensures that service users finances, which are looked after by them are protected. Records are not in place to safeguard service users. Routine servicing and maintenance checks are completed apart from 3 items. Ashton Court DS0000000392.V295154.R01.S.doc Version 5.2 Page 21 EVIDENCE: The Registered Manager is a very experienced qualified Registered General Nurse and has recently completed the Registered Manager’s Award. People spoke of their confidence in the manager and described her as fair and approachable. The Registered Person, or their representative must visit the home at least monthly and prepare a written report on the conduct of the home. There have been no reports or visits since the last inspection in January 2006. The manager has completed a quality audit of residents, relatives and staff views of the home in April 2005 but a formal system from the Registered Provider must be introduced. Resident personal finance records were examined. A file is maintained with individual sheets for each person’s transactions. Entries were suitably recorded with two signatures and numbered receipts. There was evidence of personal spending. Spot checks of balances and cash were found to be correct. Records regarding recruitment and staff are incomplete (See NMS 29) Records of fire safety checks, tests and instructions were examined. These were up to date with the exception of testing the water supply/storage, electrical equipment testing and an electric wiring certificate. Records of accidents are maintained and the Manager carries out monthly accident analysis. Ashton Court DS0000000392.V295154.R01.S.doc Version 5.2 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X X X 2 2 STAFFING Standard No Score 27 3 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X X 2 2 Ashton Court DS0000000392.V295154.R01.S.doc Version 5.2 Page 23 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 OP21 Regulation 23 Requirement Outstanding Requirement 26/04/06 The work on the upstairs shower room must be completed and made operational Mildew to tiles in shower room 2 must be removed Odour from drains in bathroom 5 must be eliminated. 2. OP25 23 Outstanding Requirement 26/04/06 Suitable ventilation must be fitted in the designated smoking room 3. OP19 23 The Registered Person must complete repairs to dining room ceiling. Remove ‘Nursing’ signage from front of building, as the home does not provide nursing care. The flooring in bedroom 8 and 28 must be replaced. Ashton Court DS0000000392.V295154.R01.S.doc Version 5.2 Page 24 Timescale for action 30/09/06 30/09/06 30/09/06 Repair the skirting boards in the kitchen, which are loose behind the dishwasher and near the refrigerators. Repair bath top cover in bathroom 4. 4. OP9 13(1) The Registered Person must ensure that ointments are included on medication administration records. The Registered Person must ensure that an annual development plan to monitor the quality of the service is introduced. Provide CSCI with a copy. The Registered Person must ensure that monthly visits and reports on the conduct of the home are completed and supplied to CSCI by the Registered Providers representative. The Registered Person must ensure that two references, CRB and POVA first checks are obtained - New staff without CRB clearance but who have POVA First checks must be supervised and accompanied by a staff member who is appropriately qualified and experienced. The Registered Person must provide CSCI with an up to date staffing training matrix Provide evidence of Legionella testing to water supply/storage. Provide evidence of electrical equipment testing. Ashton Court DS0000000392.V295154.R01.S.doc Version 5.2 Page 25 31/08/06 5. OP33 24 & 26 31/08/06 6. OP29 17 schedule 4 24/07/06 7. 8. OP30 OP38 18 23(4) 30/09/06 30/09/06 Provide an Electric wiring certificate to CSCI. 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 OP7 OP19 Good Practice Recommendations Ensure that care plans actions to meet resident’s needs is specific. (quantifiable not ‘regularly’) Replace the flooring in bedroom 25. Ashton Court DS0000000392.V295154.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Ashton Court DS0000000392.V295154.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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