Inspection on 25/01/07 for Ashview House

This inspection was carried out on 25th January 2007.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashview House 12/12/07

Ashview House 27/06/06

Ashview House 16/01/06

Ashview House 11/05/05

Ashview House 29/10/04

Ashview House 20/05/04

Similar services:

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

15 Bramble Close

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

CARE HOME ADULTS 18-65 Ashview House Riverview High Road Vange Basildon Essex SS16 4TR Lead Inspector Michelle Love Unannounced Inspection 25th January 2007 09:00 Ashview House DS0000018107.V324685.R02.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 Ashview House DS0000018107.V324685.R02.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. Ashview House DS0000018107.V324685.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashview House Address 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) Riverview High Road Vange Basildon Essex SS16 4TR 01268 583043 01268 583675 Ashview House Limited Manager post vacant Care Home 13 Category(ies) of Learning disability (13), Physical disability (3) registration, with number of places Ashview House DS0000018107.V324685.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th June 2006 Brief Description of the Service: Ashview House is a care home providing personal care and accommodation for up to thirteen residents who have a learning disability, including up to three people with physical disabilities. The home is a two storey detached house situated in a cul-de-sac, in a residential area and is close to the local amenities. There are parking facilities available to the front and side of the building, and the home has a garden with a bird aviary and chicken coop. Three mini buses are available to transport the residents to their activities and to college. The range of weekly fees charged to residents was detailed within the homes pre inspection questionnaire. The range of weekly fees is currently £938.00 to £1200.00. Additional charges incurred by residents relate to chiropody, transport, holidays, personal toiletries, hairdressing and some leisure pursuits i.e. cinema/bowling/going to the pub/visiting fast food outlets. Ashview House DS0000018107.V324685.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced `key` site visit was conducted by Michelle Love, inspector and lasted approximately 9 hours. As part of the site visit, a tour of the premises was undertaken and a number of records pertaining to care plans/risk assessments/healthcare records, staff employment files, records of staff training, menu’s/nutritional records and the homes medication storage facilities and records were inspected. The site visit was conducted with the acting manager and both senior staff and support staff were co-operative and helpful throughout the day. As part of the inspection process questionnaires/surveys were forwarded to all resident’s relatives and visiting professionals, requesting their views as to the quality of the service provided. Of those surveys sent, 7 surveys were forwarded to the Commission from resident’s relatives, however no surveys were returned from healthcare/care professionals. The outcome of these surveys has been incorporated into the main body of the report. Management/staff changes at the home have taken place since the last `key` inspection. This has resulted in a new acting manager being appointed and extensive recruitment of senior/support staff. As a result of previous concerns, a Random Inspection was undertaken to Ashview House on 18th October 2006. The main areas of focus were staffing levels, staff recruitment, the management of the home, staff interaction between staff and residents and inspection of one care plan for the newest resident. At this inspection some progress was noted. What the service does well: What has improved since the last inspection? Ashview House DS0000018107.V324685.R02.S.doc Version 5.2 Page 6 A new acting manager has been appointed. The acting manager has a good understanding of the National Minimum Standards and Care Homes Regulations and has worked very hard to address previous identified shortfalls. Despite the number of statutory requirements highlighted at this inspection, the Commission remains optimistic and pleased with the steady progress. The Commission believes that further improvement will be made by the next `key` inspection. The homes activity programme is practical and representational of individual resident’s needs. Effort has been made to ensure that there is a driver available throughout the day to support resident’s access into the community. The homes care planning processes including healthcare records have been improved upon. A new deputy manager has been appointed to support the acting manager. Additionally major changes have been made pertaining to the staff team and many new appointments have been made. A new Operations Manager has also been employed and is keen/committed to improve the home’s previous status. Following the last inspection, eighteen Statutory Requirements and ten Recommendations were highlighted, many of which had been recorded previously. At this site visit, ten Statutory Requirements and four Recommendations were featured. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ashview House DS0000018107.V324685.R02.S.doc Version 5.2 Page 7 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 Ashview House DS0000018107.V324685.R02.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose and Service Users Guide has been reviewed and updated, however some further amendments are required. The home has a system for assessing prospective residents as to their suitability to live at Ashview House. EVIDENCE: Both the Statement of Purpose and Service Users Guide have been reviewed and updated since the last key inspection. The Statement of Purpose needs to be amended as it details that the home is registered to provide nursing care. Additionally under the heading of `overview` it states that it can cater for those people who have associated mental health issues. Both statements are inaccurate and do not reflect the homes registration status. Under `resident specification` this makes reference to the home only admitting six adults. The homes registration permits up to 13 people to live at Ashview House. The Statement of Purpose also makes reference to `room sizes`, however these are not recorded. The Service Users Guide has been developed in both the written and pictorial format. The acting manager was advised that this document must also include specific information pertaining to the total fee/weekly charges payable for the cost of a placement at Ashview House, the arrangements for charging and Ashview House DS0000018107.V324685.R02.S.doc Version 5.2 Page 9 paying for any services additional to those described and whether or not charges are different for people who have all or part of their care funded by either the local authority or primary care trust. The inspector was advised that no new residents have been admitted to Ashview House since the random inspection to the home in October 2006. The registered provider has an appropriate assessment format for assessing prospective residents as to their suitability to live at Ashview House. Ashview House DS0000018107.V324685.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A plan of care is available for all residents and includes risk assessments. It remains unclear as to how residents are empowered and/or enabled to make decisions and how they participate in the day-to-day running of the home. EVIDENCE: At this inspection two individual plans of care were inspected. It was positive to note that both had been reviewed and updated. Additionally both care plans had been streamlined with historical and out of date information archived. Both care plans contained information pertaining to resident’s personal, emotional, physical, social and healthcare needs. The care plan for one resident did not include information pertaining to their physical/verbal aggression or their ritualistic behaviour. The guidelines for one resident pertaining to their personal care/shower routine etc were detailed, however it was unclear as to when these had been devised and there was no evidence to indicate that these had been reviewed or updated. The manual handling assessment for one Ashview House DS0000018107.V324685.R02.S.doc Version 5.2 Page 11 resident was noted to have been devised in January 2004 and had not been updated or reviewed. Information relating to restrictions imposed on choice and freedom for residents was partially documented. Additional information is required specifying/identifying the actual restriction and the rationale behind the decision. Risk assessments were devised for the majority of assessed areas. For one resident no risk assessments were devised in relation to their aggressive behaviours, however behaviour management guidelines were available for this person and a behaviour chart had been devised and implemented, with the last recorded entry being on 22.1.07. Daily care records were noted to be written at least twice daily. In some cases records were more detailed and informative than others and some records did not record staff’s interventions. The acting manager was advised that daily records are a good source of evidence to show that care is being provided as detailed in the care plan. Daily care records when well written help ensure a consistent approach and good quality of care for residents. Detailed daily records will help the manager to audit the care being provided to residents, and ensure that staff are following the guidelines in the care plans. It is in the homes interests to be able to show what they have done, along with providing the evidence on which to base reviews and to record that they are following the assessment of needs. There was little evidence within either care plan that it had been devised with the resident and/or their representative. Ashview House DS0000018107.V324685.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an activities programme for residents both `in house` and within the local community. Residents are enabled to maintain friendships and relationships. Residents receive a varied diet. EVIDENCE: Each resident has an activity timetable within their care plan. Additionally there is an activity board displayed in the main reception area. This details that five residents attend adult education college for various sessions (music and dancing/art and music). One resident has also enrolled to undertake a computer course and one resident attends school five days a week. Activities provided to residents are not inspirational but more realistic and in keeping with residents personal preferences, likes and dislikes. Other activities for residents include shopping, watching television/films, playing bingo, going out in the mini bus for a drive, attendance at Wednesday Club, going to Pitsea Market, cooking, arts and crafts and bowling. Of those Ashview House DS0000018107.V324685.R02.S.doc Version 5.2 Page 13 residents spoken with, all were complimentary and positive regarding activities provided. The acting manager advised that a driver is now available on every shift to enable residents to access the community. The home operates a four weekly menu for meals and these are displayed in the kitchen. On inspection of the menu’s these appear to offer residents a varied diet, with alternatives to the menu as and when required. The acting manager advised that menu’s are to be produced in a pictorial format for the future so as to enable those residents with poor communication difficulties to make an informed choice. Records indicate that one resident has been diagnosed recently as a diabetic and some residents require a healthy eating regime. Information relating to diabetes is readily available. The acting manager advised that residents are now being actively encouraged and enabled to participate in menu planning. The home has an open visiting policy whereby relatives/friends can visit the care home at any reasonable time. Ashview House DS0000018107.V324685.R02.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. 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. Residents have access to a range of healthcare professionals. Medication procedures for the safe administration of medication to residents, was observed to be appropriate. EVIDENCE: Residents care plans/associated documentation evidence residents can have access to a range of healthcare professionals as and when required i.e. Community Nurses, Consultant Psychiatrists, GP’s, Chiropodists, Dentists etc. Specialist equipment is available for residents i.e. wheelchairs, grab rails and hoists. It is positive to note that since the last key inspection where concerns were evident in relation to residents missing healthcare appointments etc, systems have been devised by the acting manager to ensure that residents attend all appointments so as to have their healthcare needs met. Since both the key and random inspection to the home, the Commission has received no complaints pertaining to the above. It is difficult to ascertain at this stage, Ashview House DS0000018107.V324685.R02.S.doc Version 5.2 Page 15 staff’s knowledge about individual residents as the majority of staff working at the care home are newly appointed. On inspection of the homes medication administration records no omissions were observed whereby the records were not signed by staff to indicate that medication had been administered to and received by residents. The acting manager was advised that the list of staff names/initials and signatures of those staff able to administer medication should be updated as soon as possible. Additionally the acting manager and senior member of staff on duty were advised that where boxes/bottles of medication are opened, these should be signed and dated once started. PRN (as and when required medication) protocols have been devised for residents. The inspector was advised that an appointment has been made to meet with the consultant psychiatrist to finalise and `sign off` each protocol. Residents are in the process of having medication reviews throughout 2007. The homes pre inspection questionnaire details that 6x people (including the acting manager/deputy manager) are responsible for administering medication to residents. The training matrix evidences that of the six staff only four have received medication training. Ashview House DS0000018107.V324685.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure. No protection of vulnerable adults issues have been highlighted since the last inspection. Some staff had received training relating to challenging behaviour. EVIDENCE: The home has a complaints procedure, however this is not displayed but located within the homes policies and procedures folder. This needs to be updated to reflect that the Commission no longer has any statutory responsibility to investigate complaints. Any complaints received at the Commission will be referred back to the registered provider or to the local authority if they are contractually involved. As part of the inspection process inspectors will examine how the registered provider has dealt with issues and as to whether regulations are being met. The pre inspection questionnaire detailed that there have been two complaints within the last 12 months. Evidence depicting details of the investigation, action taken and the outcome was only available for one complaint. A training matrix was forwarded to the Commission with the homes pre inspection questionnaire. This detailed that 8x staff do not currently have protection of vulnerable adults training and 14x staff do not have training relating to challenging behaviour. The training schedule for 2007 detailed that protection of vulnerable adults training is/has been offered by social services in Ashview House DS0000018107.V324685.R02.S.doc Version 5.2 Page 17 January 2007 and challenging behaviour training to be provided in February 2007. The home has a protection of vulnerable adults policy and procedure. Ashview House DS0000018107.V324685.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides residents with a comfortable and safe environment. EVIDENCE: On the day of the inspection the home was observed to be clean, odour free and no health and safety issues were highlighted. As stated at previous inspections, individual residents rooms were noted to be personalised and individualised with their personal effects and reflective of resident’s hobbies, interests and their likes and dislikes. Some bedrooms require redecoration and some resident’s have changed bedrooms. Although no health and safety issues were raised at this inspection, lighting within the first floor hallway (nearest office) continues to be problematic and unsatisfactory as three of the lights were not working and bulbs continue to not work/fuses blow. Ashview House DS0000018107.V324685.R02.S.doc Version 5.2 Page 19 Ashview House DS0000018107.V324685.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of vetting and recruitment practices requires some improvement. The home has a system for supervising staff. Staffing levels at the home are appropriate to meet the needs of residents. EVIDENCE: On inspection of staff rosters for the period of 27th November 2006 to 25th January 2007 inclusive, these evidence existing staffing levels as being appropriate for the numbers and needs of residents. Staffing levels are 5x support staff between 07.00 a.m. and 22.30 p.m., plus 2x staff provide 1-1 support for two individual residents between 09.00 a.m. and 17.00 p.m. and 3x waking night staff between 22.00 p.m. and 07.30 a.m. The acting manager hours are 09.00 a.m. to 17.00 p.m. Monday to Friday, however when the shifts are short the acting manager often covers and provides hands on support. Currently the newly appointed deputy manager works one long day (07.00 a.m. to 22.30 p.m.) and two day shifts (10.00 a.m. to 17.00 p.m.) each week. The shift pattern is devised in such a way that staff are on average completing 2-3 long days each week, however sufficient off duty days are scheduled. The rosters indicate that some staff are completing in excess of 62 hours per week. The acting manager was advised to monitor this and to ensure that staff, Ashview House DS0000018107.V324685.R02.S.doc Version 5.2 Page 21 remain competent and not overtired to work efficiently. No agency staff are being utilised at present and the acting manager is looking to recruit a strong and robust team of `bank staff`. There are no staff vacancies at present. Since the last inspection several new members of staff had been recruited. On inspection of five random staff recruitment files, not all records as required by regulation had been sought. This refers specifically to not all written references being received prior to the employee commencing employment at the care home, no record of induction for two members of staff, no photograph for four staff members, employment history for one person incomplete and no evidence of qualifications and training available within one file. All staff had received one supervision session. Supervision is to be conducted by the acting manager, deputy manager and senior support staff. There was no evidence to indicate that staff had received training pertaining to supervision. The acting manager advised that supervisions are planned bimonthly or sooner as required. A training matrix was forwarded to the Commission with the homes pre inspection questionnaire. It was concerning to note that according to the training matrix, 5 newly appointed members of staff had not received any training since their appointment pertaining to health and safety, manual handling, food hygiene, fire awareness, protection of vulnerable adults or infection control. Additionally there are gaps in some staff’s training and there remains little evidence in relation to specialist training to meet the specific needs of residents i.e. autism, cerebral palsy, epilepsy, rectal diazepam, diabetes etc. The training schedule for 2007 details for January/February 2007 the following training pertaining to infection control, care of cerebral palsy and feeding, activities and learning disability, autism and inclusive communication. All staff have enrolled to undertake either NVQ Level 2 or 3. Ashview House DS0000018107.V324685.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has appointed a manager to run the home. The home has developed and implemented a quality assurance system. EVIDENCE: The acting manager has been in post officially since November 2006. The acting manager is a Registered General Nurse and has worked with people who have a learning disability and/or a mental health disorder over a number of years. The acting manager is due to commence the Registered Manager’s Award in February 2007. It is clearly evident that since her appointment, she has strived very hard to run the home in line with the registered providers aims and objectives and to meet regulatory requirements in line with the Care Homes Regulations. The Ashview House DS0000018107.V324685.R02.S.doc Version 5.2 Page 23 Commission recognises her efforts to raise the home’s status and to address previous identified shortfalls. The acting manager appears competent, experienced and committed to improve standards for those people living at Ashview House. A number of surveys were forwarded to resident’s relatives to seek their views as to whether or not the care home were providing a good service. The majority of comments were positive i.e. “the home situation is now more stable”, “very pleased with the care at Ashview” and “the staff at Ashview are very professional and they always make visitors welcome”. In relation to quality assurance, the acting manager has forwarded a number of surveys to resident’s relatives, support staff and external professionals. On inspection of these surveys they were all seen to be positive, however it was disappointing that few responses had been received via various Social Services Departments. Regulation 26 visits are undertaken monthly and a report compiled by the operations manager. In addition to this a weekly operations report is undertaken by the acting manager to look at staff vacancies, staff sickness, agency hours utilised, regulation 26 issues highlighted, outstanding maintenance issues, staff training and resident reviews. There is clear evidence to indicate that staff meetings are being conducted on a regular basis. The acting manager was advised to ensure that as many people as possible attend these meetings i.e. night staff. The last resident’s meeting was conducted on 4.1.07. A random sample of records as required by regulation were inspected pertaining to fire records, emergency lighting, alarms, gas and electrical safety certificates, passenger lift certificate etc. All records were seen to be satisfactory. Ashview House DS0000018107.V324685.R02.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 2 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 2 23 1 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 1 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 X 3 X X 3 X Ashview House DS0000018107.V324685.R02.S.doc Version 5.2 Page 25 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 YA1 Regulation 4 and 5 Requirement Ensure that both the Statement of Purpose and Service Users Guide is reviewed and updated. Previous timescale of 1.9.06 not met. Ensure that individual care plans for residents, depict all of their assessed needs. Ensure that all risks are identified for all areas and recorded within individual care plans. Previous timescale of 1.9.06 not met. Ensure that all staff who administer medication to residents are competent and have received appropriate training. Ensure that complaint records reflect details of the investigation, action taken and outcomes. Ensure that all staff receive training pertaining to protection of vulnerable adults and challenging behaviour. Ensure that all areas of the DS0000018107.V324685.R02.S.doc Timescale for action 01/05/07 2. 3. YA6 YA9 15(1) 13(4)(c) 01/05/07 01/05/07 4. YA20 18(1)(c)(i) 14/05/07 5. YA22 22(8) 14/04/07 6. YA23 13(6) 01/07/07 7. YA24 23(2)(p) 01/05/07 Page 26 Ashview House Version 5.2 home are well lit and in full working order. This refers specifically to the first floor hallway. Previous timescale of 14.8.06 not met. Ensure that staff are competent. This refers specifically to staff not working excessive hours. 8. YA33 18(1)(a) 14/04/07 9. YA34 19 Previous timescale of 14.8.06 not met. Ensure that robust recruitment 14/04/07 procedures are adopted and that all records as required by regulation are sought and available. 10. YA35 Previous timescale of 14.8.06 not met. 18(1)(C)(i) Ensure that all staff receive appropriate training and all newly appointed staff receive an induction. Previous timescale of 1.12.06 not met. 01/07/07 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. 3. 4. Refer to Standard YA6 YA20 YA20 YA22 Good Practice Recommendations As part of good practice procedures, ensure that daily care records are written after each shift. As part of good practice procedures update the list of staff names/signatures and initials, which depict those staff able to administer medication to individual residents. Ensure that where bottles and packets are opened these are dated and signed. Update the homes complaints procedure to reflect that the Commission no longer investigates complaints. DS0000018107.V324685.R02.S.doc Version 5.2 Page 27 Ashview House Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ashview House DS0000018107.V324685.R02.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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