Inspection on 28/12/06 for Ashville House

This inspection was carried out on 28th 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 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 22 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashville House 27/11/07

Ashville House 26/06/07

Ashville House 04/07/06

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Ashville House 117 Ashville Road Leytonstone London E11 4DS Lead Inspector Sandra Jacobs-Walls Unannounced Inspection 28th December 2006 11:45 Ashville House DS0000064958.V322803.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 Ashville House DS0000064958.V322803.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. Ashville House DS0000064958.V322803.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashville House Address 117 Ashville Road Leytonstone London E11 4DS 020 8281 2236 020 8281 2236 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) April Rai Ms Shelley Okwuosa Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Ashville House DS0000064958.V322803.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th July 2006 Brief Description of the Service: Ashville House is a small home offering support, guidance and accommodation to a maximum of three service users who have mental health support needs. As of January 2006, new proprietors, who had purchased the business from its previous owners, were registered with CSCI. There is a new registered manager in place. The home’s premises are a two-storey terraced house, which contains a lounge, small dining area annexed to the kitchen and a small staff office. All bedrooms are single, two of which are situated on the first floor with the other on the ground floor. There are two toilets and one bath, all situated on the first floor. The building is therefore not suitable for sometimes who has mobility difficulties. There is a small garden to the rear. The home provides services to both men and women; at the time of the inspection three service users were living at the home, one male, two female. Ashville House DS0000064958.V322803.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection of Ashville House took place on December 28th 2006 for the duration of seven hours. The support worker on shift assisted the inspector initially and was later joined by the home’s registered manager. The purpose of the inspection was to assess the home against key National Minimum Standards and gauge the home’s success in addressing requirements made at the last inspection that was conducted in July 2006. The inspection process included the interview of all three service users living at the home at the time of the inspection, interview with staff, the review of key policies and procedures and other documentation, the review of one service user’s file in detail, the review of four staff files and an accompanied tour of the home’s premises. As a result of the inspection findings, twenty-two (22) requirements and one (1) recommendation was made. The inspector would like to thank all staff and service users who co-operated and contributed to the inspection. What the service does well: What has improved since the last inspection? It was the inspector’s view that the service continued to function at similar levels noted at the previous inspection. Little progress had been made in improving the overall service provided which was worrying. However it was noted that written service user contracts were evidenced on file, the home’s complaints procedure more explicitly identified management roles, staff had Ashville House DS0000064958.V322803.R01.S.doc Version 5.2 Page 6 received training in food hygiene and the home’s visitor’s book was being utilised more consistently. These issues had been subject to requirements at the last inspection. 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. Ashville House DS0000064958.V322803.R01.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 Ashville House DS0000064958.V322803.R01.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, 2 & 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection, one new service user had been admitted to the home. The inspector reviewed the file of this service user. The inspector was pleased to note that a written license agreement was in place as this had not been the case at the previous inspection. The last inspection had highlighted the need for the home to amend the Service User Guide to ensure its contents were in compliance with the regulations. During the inspection, the inspector requested to see the Service User Guide document however, it was not produced. The registered manager later commented that further amendments were required and the revised document was not available, but in the process of being printed. The requirement is therefore repeated. The review of the service user’s file evidenced good background information that had been obtained at the point of referral and documented assessments seen on file were comprehensive. Ashville House DS0000064958.V322803.R01.S.doc Version 5.2 Page 9 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 & 9 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The review of the service user’s file evidenced good background information that had been obtained at the point of referral. However the home’s documented care plan did not explore fully all the service user’s needs as identified by the placing authority; issues regarding personal care needs and food intake, apparent when the service user was unwell did not appear on the care plan. Service users who spoke with the inspector indicated that they felt they had good opportunities to make decisions for themselves. They commented that they were free to go where they wanted and had freedom of movement around their home. Service users also said they made decisions about the menu and wanting to spend time by themselves. The support worker assisting with the inspection commented that service users were encouraged to make decisions about the decoration of their bedrooms, what Christmas decorations they Ashville House DS0000064958.V322803.R01.S.doc Version 5.2 Page 10 wanted for communal areas and one service user had decided to enrol on a fashion and design college course. The previous inspection had highlighted the need for the home’s risk assessment tool to be developed further. The inspector was satisfied that this piece of work had been completed but in reviewing the risk assessment in place for one service user it was noted that the home’s own documented risk assessment was incomplete. This was unacceptable as the service user had been living at the home for some five months and information provided by the placing authority had been comprehensive. The service must ensure that fully completed risk assessments are evidenced on file to enhance the safety and wellbeing of service users and staff. The previous inspection had also highlighted the need for the home to develop an Access to Files policy. On this occasion, the relevant policy document was produced and was reviewed. The Access to Files policy seen was considered to be in need of revision, namely to identify how service users and/or their advocates can gain access to information. It was unclear to the inspector whether verbal requests could be made, which is in contradiction to data protection guidelines, which establish that written requests are required. Ashville House DS0000064958.V322803.R01.S.doc Version 5.2 Page 11 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 & 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff and service users themselves informed the inspector that to varying degrees all service users attended local day centres. This appears the main source of recreational activity enjoyed by service users. In addition, staff and service users told the inspector that occasional day trips around London had been organised by the home. Recent trips had included a trip to Madam Tussauds and a museum. Service users had also enjoyed a short break to Centreparcs earlier in the year. These trips were clearly very much anticipated and enjoyed by service users, including one service user who previously had been reluctant to participate in any activity outside the home. Additionally, service users are encouraged to make use of the local community by way of taking walks, going shopping, visiting the hairdresser for example. Service users and staff informed the inspector of the frequent visits to service users’ family members by service users. One service user in particular visited Ashville House DS0000064958.V322803.R01.S.doc Version 5.2 Page 12 the family household on a weekly basis. Another service user enjoyed occasional visits to the home by her children. With regard to meals, service users indicated to the inspector that they enjoyed food provided by the home and that choices were made during residents’ meetings. The inspector asked to see the menu planner for the week of the inspection, Christmas week, but this was not produced. The inspector then reviewed the home’s menu plans for a number of weeks preceding the inspection date and noted that the weekly menus were identical in content. The registered manager commented that the menu plans seen were not a true reflection of the choice of meals provided, but could not offer an explanation as to why meals actually eaten by service users were not documented on the menu planner in the space provided. The home must ensure that weekly menu plans are varied, that individual menu choices are appropriately documented and that all weekly menu plans are made available on site. Ashville House DS0000064958.V322803.R01.S.doc Version 5.2 Page 13 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, 20 & 21 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff interviewed by the inspector commented that largely, service users were able to complete personal care tasks independently; staff were required to supervise and prompt only. The service user file reviewed supported this view and service users verbally confirmed this practice to be true. The file reviewed contained good background information detailing the physical and emotional needs of the service user and the care plan offered the nature of support to be made available to meet these needs. The service user file reviewed contained information about the service user’s medication regime and an appointment made for cervical screening. Service users who spoke with the inspector indicated that their physical health and mental health support needs were being met by the home. Staff interviewed demonstrated fair knowledge of service users’ medical needs including the need for periodic blood tests for one service user and his need to wear prescription glasses. All service users were registered with GP’s and had access to opticians and dental services. The home is yet to develop policies that relate to illness and aging, although a policy relating to the management of the death of the service user was seen. Ashville House DS0000064958.V322803.R01.S.doc Version 5.2 Page 14 The previous inspection had highlighted poor practices in staff’s administration and management of service users’ medication. On this occasion the inspector reviewed the medication information for two service users. The inspector noted that for one service user there was no documentation for the course of sleeping tablets prescribed for seven days duration. The registered manager explained that the service user in question had taken the first of the seven tablets and thereafter refused to take any others. No documentation was evident to confirm this. The home’s medication cabinet contained six tablets of the same medication, prescribed back in October 2006 which was yet to be disposed. The inspector also noted that for another service user the MAR (Medication Action Record) sheet evidenced an unexplained gap, making it impossible to determine whether the medication had been offered, not offered, taken or refused. These practices were clearly in contradiction with the home’s medication policies and were not conducive to safe medication administration. Staff must improve upon medication practices in the home in order to enhance the safety and well being of service users living at Ashville House. Ashville House DS0000064958.V322803.R01.S.doc Version 5.2 Page 15 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 & 23 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s complaints procedure had been revised as per the findings of the previous inspection. However, further revision was recommended for the procedure to be appropriately linked to the home’s adult protection procedures. The inspector reviewed the home’s complaints log, which evidenced that no complaints had been made since the last inspection. Similarly, service users who spoke with the inspector indicated that they had not felt the need to make any complaint against the home. With regard to adult protection, the home’s adult protection procedures indicate that all allegations should be recorded in the ‘concerns book’, however, when asked to produce this log, the support worker failed to do so. In discussion with the registered manager later during the inspection, it became apparent that despite the guidelines in the policy document, no such log existed in the home. An accident/incidents book was reviewed, the inspector was satisfied that this log contained no records of any incident of an adult protection nature. The home must develop a log specific to the recording of any allegations/incidents of an adult protection nature. This is an outstanding requirement from the previous inspection. The inspector reviewed the home’s existing policy in detail. Staff failed to produce local/host (social services) adult protection policies to ensure the home’s policy was in accordance with local (authority) protocols. The registered manager produced the home’s ‘Protection of Vulnerable Adults & Ashville House DS0000064958.V322803.R01.S.doc Version 5.2 Page 16 Prevention of Abuse’ policy. The document wrongly advised staff that suspicion/allegation of abuse against the home’s managers/director “should be made directly to NCSC”. This is also in contradiction to safeguarding policies. The registered managers must ensure that the home’s adult protection polices comply with those of the host local authority and that a copy of the (local authority) document is maintained on site. Ashville House DS0000064958.V322803.R01.S.doc Version 5.2 Page 17 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, 27 & 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the inspection the home’s premises were clean and hygienic. The inspector noted that redecoration to the bathroom had been completed, but the lock to the first floor toilet was broken and was in need of repair. The previous inspection had highlighted the need for staff to make appropriate use of the home’s fire doors and that these remain closed to minimise the spread of any fire in the home. The inspector noted that the same observation had been made by LFEPA during a fire inspection conducted at the home in March 2006. The home had subsequently received a letter alerting staff of the dangers to keeping fire doors propped open. Despite this however, on the day of the inspection the inspector observed the lounge fire door, the kitchen fire door and the fire door to the staff room all propped open with doorstoppers. The inspector considered this to be blatant disregard of safety warning made by both CSCI & Ashville House DS0000064958.V322803.R01.S.doc Version 5.2 Page 18 the fire authority in an attempt to safeguard service users and staff in the event of a fire. The inspector then asked to see the home’s health and safety and in particular its fire safety/precaution policies. None were produced that were specific to the home, although the inspector had seen earlier a blank template for fire safety procedures and evacuation plans for a London based NHS facility. The registered manager explained that she had intended to use the template as guidance to developing the home’s own fire safety policies. This was clearly wholly inadequate and placed service users and staff at considerable risk in the absence of viable health and safety policies and procedures. This issue must be resolved as a matter or priority. Ashville House DS0000064958.V322803.R01.S.doc Version 5.2 Page 19 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): 32,34 & 35 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users who spoke with the inspector indicated that they felt staff worked well with them. The registered manager commented that staff training was ongoing, but no staff appraisals had taken been completed since the proprietors purchased the home. It was the inspector’s view that staff appraisals were a good method in assessing staff competencies and that these must be completed as a matter of urgency. The inspector was aware that some staff had not participated in an induction once employed to work at the home. This is poor practice and potentially could compromise the safety of service users and staff.. The previous inspection had highlighted the need for staff files to evidence full information as specified in Schedule 2 of the Care Homes Regulations. On this occasion, the inspector reviewed the personnel files for three staff members, of which two failed to evidence full information as required. For example, one file seen failed to evidence a CRB disclosure applied for by the provider. The existing CRB had been obtained via a previous employer. The registered manager commented that a new CRB had been applied for however there was no evidence on file to confirm this. Of the three staff files reviewed, two Ashville House DS0000064958.V322803.R01.S.doc Version 5.2 Page 20 evidenced only one written reference; the regulations require two written references for each staff member. The inspector also asked to review the personnel file for one of the company directors, who on occasion worked shifts at the home and conducted monthly monitoring visits, but no file was produced. The service must ensure as a matter of priority that staff records evidence all information as outlined in Schedule 2 of the Care Homes Regulations. This is particularly worrying, as the previous inspection had similarly highlighted this aspect of the home as being weak. Compliance with Schedule 2 of the regulations is essential to enhance the protection and safety of service users. Ashville House DS0000064958.V322803.R01.S.doc Version 5.2 Page 21 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, 42 & 43 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The body of this report has highlighted a number of very serious weaknesses to the operation and management of Ashville House. Areas in need of improvement directly affect the home’s ability to protect and keep safe its service users and staff. Key policies and procedures are in need of development as are the home’s health and safety systems. Required staff information is inadequately maintained and service user information seen on file is in need of improvement. The home has self-monitoring systems in place, that is, monthly monitoring visits are conducted and subsequent reports are produced and shared with staff members and CSCI. However, the effectiveness of the monitoring visits must be questioned as these have failed to highlight and offer solutions to many of the areas identified in this report as being in need of attention. The Ashville House DS0000064958.V322803.R01.S.doc Version 5.2 Page 22 home’s monitoring visits much be more robust and effective in reviewing the home’s performance and offering resolution. This report has highlighted poor recording in a number of areas as being problematic. In reviewing the home’s staffing rota for the week of the inspection is was noted that as with the previous inspection, that the rota contained inaccurate information about staff cover. Staff rotas must be an accurate reflection of shifts worked by individual staff members and any amendments to the rota must be promptly made. This is a repeat requirement. It is the inspector’s view that service users of Ashville House do not benefit from competent and accountable management of the service and that as a result, the health safety and wellbeing of service users are compromised. This is wholly unacceptable and failure to improve services at the home may result in the consideration of CSCI pursing further action. The inspector would strongly encourage the management of Ashville House take prompt action to effectively address this very worrying situation. Ashville House DS0000064958.V322803.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 1 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 2 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 2 2 X 1 X X 1 2 Ashville House DS0000064958.V322803.R01.S.doc Version 5.2 Page 24 YES 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 YA1 Regulation 5 Requirement The registered manager must ensure that the home’s Service User Guide is compliant with the regulations and is available on site for appropriate distribution. (Previous timescale of 01/06/05 & 01/09/06 not met) The registered manager must ensure that service user care plans detail fully all identified needs to be met by the home The registered manager must ensure that all service users’ file evidence fully completed risk assessments The registered manager must develop an Access to Files policy that outlines the procedure for information/files to be reviewed by service users and/or their advocates. The registered manager must ensure that weekly menu plans are varied and that individual menu choices are appropriately documented and that all weekly menu plans are made available for the purpose of inspection. Timescale for action 31/03/07 2. YA6 15 31/03/07 3. YA9 14 31/03/07 4. YA10 12 31/03/07 5 YA17 17(2) 31/03/07 Ashville House DS0000064958.V322803.R01.S.doc Version 5.2 Page 25 6. YA20 13(2) 7. 8. YA20 YA20 13(2) 13(2) 9 YA20 13(2) 10. YA21 12(1) 11. YA23 12 (1) 12 YA23 13(6) 13 YA23 13(6) 14 YA27 12(4)(a) 15. YA24 23(4)(a) The registered manager must ensure that the home’s practices’ in relation to medication is in compliance with the home’s written medication policies. The registered manager must ensure that MAR sheets are accurately completed by staff The registered manager must ensure that all staff receives appropriate medication training. (Previous timescale of 01/07/05 & 01/10/06 not met) The registered manager must ensure that all unused medication is appropriately disposed. The registered manager must produce and implement written policies relating to the ageing and illness service users The registered manager must develop and evidence a system that records centrally all allegations of an adult protection nature. (Previous timescale of 01/09/06 not met) The registered manager must ensure that the home’s adult protection policies are revised to comply with safeguarding policies of the host local authority The registered manager must ensure that a copy of the host local authority’s adult protection procedures is maintained on site. The registered manager must ensure that the broken lock to the first floor bathroom is repaired The registered manager must ensure that the kitchen door is repaired to automatically close upon release and is not kept propped open. (Previous timescale of February 2005 & 15/08/06 not met) DS0000064958.V322803.R01.S.doc 28/02/07 28/02/07 31/03/07 28/02/07 31/03/07 28/02/07 28/02/07 28/02/07 28/02/07 28/02/07 Ashville House Version 5.2 Page 26 16. YA24 23(4)(a) 17. YA24 23 18. YA32 18 19. YA34 19 20. 21. YA35 YA39 18 24 22. YA41 17(2) The registered manager must ensure that all fire doors in the home are kept closed and not propped open. The registered manager must develop and implement robust health and safety policies and procedures, which include fire safety precautions. The registered manager must ensure that all staff appraisals are conducted. (Previous timescale of 01/10/06 not met) The registered manager must ensure that staff personnel records evidence full information as specified in Schedule 2 of the Care Homes Regulations. (Previous timescale of 01/06/05 & 01/09/06 not met) The registered manager must ensure that all new staff participates in an induction. The registered person must ensure that monthly unannounced monitoring visits are effective in identifying areas of weakness in the home’s functioning and that appropriate action is taken to address noted deficiencies. The registered manager must ensure that the staff roster is maintained accurately and show the hours of all staff worked including the registered manager. (Previous timescale of 01/05/05 & 01/09/06 not met) 28/02/07 31/03/07 31/03/07 31/03/07 28/02/07 31/03/07 28/02/07 Ashville House DS0000064958.V322803.R01.S.doc Version 5.2 Page 27 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 YA22 Good Practice Recommendations It is recommended that the home’s complaints procedure be amended to make clear that complaints of an adult protection nature will be managed via the home’s adult protection policies and procedures. Ashville House DS0000064958.V322803.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection East London Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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 Ashville House DS0000064958.V322803.R01.S.doc Version 5.2 Page 29 - 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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