Inspection on 04/07/06 for Ashville House

This inspection was carried out on 4th 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 21 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 28/12/06

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 Key Unannounced Inspection 4th July 2006 02:00 Ashville House DS0000064958.V301380.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.V301380.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.V301380.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.V301380.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 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 two service users were living at the home, one male, the other female. Ashville House DS0000064958.V301380.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 was conducted over the course of two days. It was the home’s first inspection following the registration of new ownership of the service. The inspection assessed the home against all National Minimum Standards. The inspection process included discussion with the registered manager, the review of two service user files, interview with one service user present on the second day of the inspection, review of key policies and procedures and other relevant documentation. The inspector interviewed one care worker and reviewed the staff personnel files for three members of the staff team. As a result of the inspection twenty-one (21) requirements and no recommendations were 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? The inspector acknowledged that there had been a number of outstanding concerns (and thus requirements) for the service while under the management of the previous owners. The new proprietors having bought the home as a going concern had inherited many of these issues. Some attempt had been made to address identified weaknesses, while the inspection highlighted Ashville House DS0000064958.V301380.R01.S.doc Version 5.2 Page 6 others. The inspector was satisfied however, that in general outcomes for service users were positive. 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. Ashville House DS0000064958.V301380.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.V301380.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 & 5 Quality in this outcome area is adequate. This judgment had been made using available evidence including a visit to this service. EVIDENCE: The previous inspection had highlighted the need for the home’s Statement of Purpose document and Service User Guide to be revised. The inspector reviewed the home’s current Statement of Purpose and was satisfied that it contained all information as specified in the regulations. The registered manager informed the inspector that the home’s Service User Guide was still in draft form and due to be issued shortly. The inspector was informed that the home had received two recent referrals and was in the process of completing preliminary assessments. With regard to written service user contracts, none were evidenced on either of the service user files reviewed. The registered manager informed the inspector that these were being draft, soon to be shared and issued to service users and/or their advocates. Ashville House DS0000064958.V301380.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 & 10 Quality in this outcome area is adequate. This judgment had been made using available evidence including a visit to this service. EVIDENCE: The inspector was satisfied that both service user files seen contained documented care plans that had been devised by staff of the home. However the registered manager acknowledged that for one service user, the care plan seen was not the most current. The revised care plan on the day of the inspection was unavailable for review. The home must ensure those care plans maintained on service users files are current. The other service user’s file seen had been subject to recent re-assessment by the placing authority. The inspector was satisfied that service users were consistently consulted about aspects of life in the home and were encouraged to participate in the decision making process. The registered manager gave examples that demonstrated service users were encouraged to make decision for themselves. Menus were devised based on the preferences of service users, and residents meetings, which were held regularly explored a wide range of issues for service users to consider. Review of the minutes of the home’s residents meetings Ashville House DS0000064958.V301380.R01.S.doc Version 5.2 Page 10 revealed that issues such as recreational activities, holiday opportunities, the re-decoration of shared space and the purchase of Sky cable were all decided upon by service users. The inspector also saw on individual service user files evidence of service users participation in the decision making process. For example one service user had decided not to attend a number of scheduled medical appointments made on her behalf despite encouragement by staff. Service users’ files also contained documented risk assessments that generally covered risks poses as a result of their mental health support needs. It was the inspector’s view that the risk assessment tool used was somewhat limited in identifying risks other than those posed directly as a result of service users mental health support needs and that there were other wider, areas of risk that also needed to also feature. For example risks posed to the personal safety issues for the service user whose behaviour was known to be challenging while out in the community. Use of a more comprehensive risk assessment tool may assist improve the quality of service user’s risk assessments. The inspector was generally satisfied that service user’s information was handled confidentially. All service user information was kept securely locked in cabinets in the staff office. Computers used by staff were password protected. However, the home will need to develop an Access of Files Policy to advise service users/their advocates of their right to review information written about service users that is maintained by the home. Ashville House DS0000064958.V301380.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 & 17 Quality in this outcome area is good. This judgment had been made using available evidence including a visit to this service. EVIDENCE: The registered manager gave examples of the home’s attempts to enhance the personal development of individual service users. The inspector was informed and saw on file details of daily chores service users were encouraged to complete for themselves. These tasks included completing personal laundry making snacks and drinks independently of staff and making independent use of public transport. The registered manager commented that one service user’s personal development had significantly improved that she was able to go on holiday for the first time ever and now attend a day centre. Both service users’ attend day centres and also participated in peer and cultural activities. The registered manager informed the inspector that one service user, who was Asian in origin had requested that he and the home celebrate Diwali a Hindu festival. Staff accompanied him to a local resource to participate in Diwali celebration and the home also celebrated by offering specific appropriate cultural meals. The other service user, Irish in origin had expressed a preference for spending recreational time and participating in Ashville House DS0000064958.V301380.R01.S.doc Version 5.2 Page 12 traditional Caribbean activities. Staff made a referral to a local African/Caribbean day centre, which was accepted. With regards to accessing the local community, the registered manager commented that service users were encouraged to make choices with regard to where they went and visited. If service users were unable to access the local community independent of staff, they were accompanied. Generally service users attended the local library, the high street for shopping and local restaurants for meals out. The service user who spoke with the inspector confirmed this. Some service users would use public transport to travel further a field for other shopping opportunities. The registered manager informed the inspector that one service user had frequent contact with his immediate family; he visited and stayed over on bank holidays & some weekends and at other times if other relatives were in the UK. The other service user had limited face-to-face contact with family members. The inspector reviewed a weekly menus plan and was satisfied that meals offered were varied and nutritiously balanced. The registered manager commented that one of the service users, who was Irish in origin had a particular liking for potatoes, while the home’s other service user, (who was Asian in origin) occasionally requested traditional Asian foods. Expressed dietary preferences featured on the weekly menu that was reviewed by the inspector during the inspection. Ashville House DS0000064958.V301380.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. This judgment had been made using available evidence including a visit to this service. EVIDENCE: The registered manager informed the inspector that service users themselves largely perform personal care tasks; staff mostly offered support, prompting and supervision of the completion of personal care tasks. Files seen contained good information regarding the healthcare and emotional needs of service users. For example, staff were advised to be vigilant about the changing moods of one service user in particular, who was prone to depressive states. Review of the other service user’s file revealed good evidence of the monitoring of the service users medical needs, in particular hospital neurology appointments and medication reviews. The previous inspection report had highlighted the need for the home to improve upon its medication practices. In addition, staff were in need of medication training. During the inspection, the home’s medication policy was reviewed. The policy, whilst comprehensive, it was unclear to the inspector whether this was the most recent policy document (dated 2000). The policy made reference to guidance on the disposal of medication and the development of individual medication profiles in the main file. Neither of these Ashville House DS0000064958.V301380.R01.S.doc Version 5.2 Page 14 provisions were evident on information produced, the home must either fully comply with its written policies or amend the policy to reflect actual practice. The inspector then reviewed the medication information in detail for one service user. It was noted that prescribed skin ointment used (as required) did not feature of the MAR (Medication Action Records) sheets. This is not conducive to safe medication practices. Also noted on MAR sheets, was the need for specific times to be documented when medication was to be administered. MAR sheets seen at the time of the inspection indicated only “am” or “pm”. This again is not conducive to safe medication practices. The inspector was informed that medication training for staff remained outstanding but that training had been arranged for September 2006. The inspector asked to see the home’s policy and practice in relation to the ageing, illness and death of service users but no policy document was could be located/produced. The registered manager must produce and implement relevant policy documents. Ashville House DS0000064958.V301380.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is poor. This judgment had been made using available evidence including a visit to this service. EVIDENCE: The previous inspection had highlighted the need for the home to amend the complaints procedure to make clear who would be responsible for any complaint made against the manager. The policy and procedure also needed to be linked in with the home’s adult protection procedures. The inspector reviewed the home’s complaints procedure that was in need of further revision to clarify that the ‘Service Manager’ and ‘Director’ were in fact the same person, responsible for the investigation of any complaint against the home’s manager. The policy still needs to be linked to the home’s adult protection procedures, outlining that these policies are to be implemented if the complaint was of an adult protection nature. The inspector was informed that no allegations of abuse had been made since the last inspection. The inspector reviewed the home’s adult protection procedures. The information was clear and comprehensive however made reference to staff documenting all allegations in the home’s ‘Concerns book’. The inspector asked to review this book, which was not produced. The registered manager must ensure that the concerns book or an alternative system is in place to centrally record all allegations of an adult protection nature. Ashville House DS0000064958.V301380.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29 & 30 Quality in this outcome area is adequate. This judgment had been made using available evidence including a visit to this service. EVIDENCE: The inspector participated in an accompanied tour of the home’s premises. Previously, a requirement had been made for an appropriate lock to be placed on the bathroom door. This had been completed. The maintenance of the building is adequate. All service user bedrooms were seen and were considered satisfactory. The service users who spoke with the inspector indicated that she was pleased with her living environment and her bedroom in particular. Communal areas were also considered satisfactory. The kitchen area was suitably equipped, PAT testing of appliances had been conducted in December 2005 and laundry facilities were adequate. Fire doors must remain closed and not propped open, the kitchen door in particular must be repaired to ensure automatic full closure upon release. The first floor bathroom is in need of general re-decoration; the registered manager commented that this had already been planned to take place over the summer months. Ashville House DS0000064958.V301380.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 & 36 Quality in this outcome area is poor. This judgment had been made using available evidence including a visit to this service. EVIDENCE: The new owners of the home had continued to employ the majority of care staff previously working in the home. The registered manager said that individual job descriptions were in place. The inspector reviewed the personnel files for three members of staff and was satisfied that generally, staff were suitably experienced, however staff must receive training in food hygiene. The registered manager commented that the staff team were well established and worked well together to meet service users’ identified needs. The service user who spoke with the inspector indicated that she was satisfied with the performance of staff. The registered manager commented that she was in the process of identifying the training needs of staff and had already begun the process of securing relevant training opportunities. The inspector felt that this process would be assisted by the completion of staff appraisals. Training offered by the training body identified to meet staff training needs was said to be wide ranging and training could be tailored to suit the needs of the staff group. The inspector is concerned of the findings of the review of three staff personnel staff files. Files seen failed to evidence full information required to be Ashville House DS0000064958.V301380.R01.S.doc Version 5.2 Page 18 maintained by the home as per Schedule 2 of the Care Homes Regulations. One staff file reviewed contained no positive proof of identity; the second staff file contained no written references, proof of identity, nor details of a completed employment history. The third staff file also contained no evidence of written references; there was no evidence of CRB disclosure form, nor details of an employment history. This situation is extremely worrying and is in clear breach of the regulations. This situation must be resolved as a matter of priority in order to enhance the safety of service users living in the home. Staff interviewed during the inspection commented on the long shift hours they had been accustomed to working. The registered manager confirmed that staff worked shifts of up to 12 hours. A previous requirement had highlighted this working practice as an issue and advised that staff hours be reviewed to ensure these were consistent with the Working Time Regulations, which ensured the health and safety of both staff and service users. This requirement is repeated. The review of staff files also failed to evidence consistent 1:1 individual staff supervision and as mentioned previously, the appraisal of staff. These systems must be effectively implemented if the support of staff and ultimately their performance in meeting service users’ needs is to improve. This issue was subject to a requirement at the previous inspection and is repeated for this inspection. Ashville House DS0000064958.V301380.R01.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. This judgment had been made using available evidence including a visit to this service. EVIDENCE: The inspector was clear that the new owner/proprietors of the home had made fair effort to run the home efficiently, despite having inherited a number of issues. Nonetheless, the inspector was of the view that since the registration of the new owners with CSCI had taken place several months ago and the fact that the new management structure had been in place for almost a year that many of these issues should have been resolved, in particular, the appropriate maintenance of staff records, the development of effective key policies and procedures and service user information. The inspector noted that upon entry to the home, on two separate occasions that she was not invited to sign the visitor’s book. The consistent use of the home’s visitor’s book is essential to safeguard service users’ living in the home. Ashville House DS0000064958.V301380.R01.S.doc Version 5.2 Page 20 The home maintained records that related to health and safety matters, but could not produce documented evidence of fire drills having taken place. The home must consistently conduct and document the outcome of the fire drills to safeguard the safety and well-being of service users and staff. The service will need to develop robust and consistent monitoring systems to ensure identified deficiencies in service provision are effectively resolved. This is to include monthly unannounced monitoring visits of which reports must be produced and acted upon. Ashville House DS0000064958.V301380.R01.S.doc Version 5.2 Page 21 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 N/A 4 N/A 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 2 29 X 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 1 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 2 LIFESTYLES Standard No Score 11 3 12 4 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 2 2 2 2 2 1 1 2 Ashville House DS0000064958.V301380.R01.S.doc Version 5.2 Page 22 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 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 not met) The registered manager must issue all service users with written contracts that are evidenced in file. The registered manager must develop a comprehensive risk assessment tool that explores wide areas of risk. The registered manager must develop and implement an Access to Files policy that facilitates service users having access to information about them that is maintained by the home. 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 specify actual times medication is to be DS0000064958.V301380.R01.S.doc Timescale for action 01/09/06 2. YA5 17(2) 01/09/06 3. YA9 14 01/10/06 4. YA10 12 01/10/06 5. YA20 13(2) 01/09/06 6. YA20 13(2) 01/09/06 Ashville House Version 5.2 Page 23 administered. 7. YA20 13(2) The registered manager must ensure that staff receive appropriate medication training. (Previous timescale of 01/07/05 not met) The registered manager must produce and implement written policies relating to the ageing, illness and death of service users The registered manager must ensure that the home’s complaint’s procedure is appropriately amended to • Clarify the role of the ‘service manager’ and ‘Director’ • Link the procedure with the home’s adult protection policies (Previous timescale of 01/06/05 not met) The registered manager must develop and evidence a system that records centrally all allegations of an adult protection nature. 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 not met) The registered manager must ensure that the first floor bathroom is re-decorated The registered manager must ensure that all staff receive training in food hygiene The registered manager must review staff hours to ensure that they are consistent with the Working Time Regulations. The registered manager must be aware of their responsibilities under the regulations and be DS0000064958.V301380.R01.S.doc 01/10/06 8. YA21 12(1) 01/10/06 9. YA22 22 01/10/06 10. YA23 13(6) 01/09/06 11 YA24 23(4)(a) 15/08/06 12. 13 14. YA28 YA32 YA33 23(2)(d) 13(4)(c) 18 01/10/06 01/11/06 01/10/06 Ashville House Version 5.2 Page 24 15 YA34 19(1) 16 YA35 18 17 YA36 18 18 YA39 24 19 YA41 17 20 YA42 17(2) 21 YA42 23(4) able to demonstrate their compliance. (Previous timescale of 01/06/05 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 01/05/05 not met The registered manager must develop and offer staff comprehensive training that includes appropriate NVQ training. (Previous timescale of 01/06/05 not met) The registered manager must ensure that all staff receive regular supervision which is documented and that staff appraisals are conducted. The registered manager must ensure that monthly unannounced monitoring visits are consistently conducted and reported upon. Reports must be shared with CSCI. 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 not met) The registered manager must ensure that all visitors sign the home’s visitor’s book upon entry to the home. The registered manager must ensure that the home consistently conduct and document the outcomes of the home’s fire drills. 01/10/06 01/09/06 01/10/06 01/09/06 01/09/06 01/09/06 01/09/06 Ashville House DS0000064958.V301380.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ashville House DS0000064958.V301380.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ 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 Ashville House DS0000064958.V301380.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!