Inspection on 29/03/07 for Aspray House

This inspection was carried out on 29th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Aspray House 10/12/07

Aspray House 25/06/07

Aspray House 22/02/06

Aspray House 25/08/05

Aspray House 17/03/05

Aspray House 19/11/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Aspray House 481 Leabridge Road Leyton London E10 7EB Lead Inspector Zita McCarry Unannounced Inspection 11:30 29 March 2007 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Aspray House DS0000044296.V328396.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Aspray House DS0000044296.V328396.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Aspray House Address 481 Leabridge Road Leyton London E10 7EB 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) 020 8558 9579 0208 558 9052 Twinglobe Care Homes Ltd Ms Julie Burton Care Home 64 Category(ies) of Dementia - over 65 years of age (44), Old age, registration, with number not falling within any other category (20), of places Physical disability over 65 years of age (20) Aspray House DS0000044296.V328396.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The `DE` and `PE` Categories specified relate to service users who are 55 years old and over. 22nd February 2006 Date of last inspection Brief Description of the Service: Aspray House is a registered care home for 64 older people. The home is registered to provide dementia care for 44 people and nursing care for 20 people including care for people with physical disabilities. The home was first registered as Twinglobe Care Home and subsequently changed the name to Aspray House. The home is part of Twinglobe Care Homes Limited. The home is situated at the heart of Leyton in the London Borough of Waltham Forest. The home is within easy access to public transport, shops and other community amenities. The home was registered with the Commission for Social Care Inspection (CSCI) on 13.8.04, providing 64 beds with en-suite facilities in four suites: Emerald and Opal with 20 beds each, and Sapphire and Topaz, each with 12 beds. Aspray house is a purpose built care home, which provides all modern equipment and facilities for service users. The bedrooms are spacious, light and airy. All have en-suite facilities, and assisted bath and shower rooms are close by. Aspray House DS0000044296.V328396.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is a report of an inspection undertaken at the end of March 2007. The inspection was unannounced and undertaken by two inspectors. As part of the inspection process records pertaining to the care of service users and documents about the running of the service were reviewed. They inspectors undertook a tour of the home and spoke with service users, staff and visitors. The inspectors would like to thank everyone for their co-operation and hospitality during the day. What the service does well: What has improved since the last inspection? What they could do better: The service must review its pre admission assessment process. The service will need to ensure it adheres to its own complaints and adult protection processes. The service will need to ensure service users medication is managed appropriately. Aspray House DS0000044296.V328396.R01.S.doc Version 5.2 Page 6 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. Aspray House DS0000044296.V328396.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Aspray House DS0000044296.V328396.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The service has failed to adequately assess service users needs prior to admission and subsequently placed other service users at risk of harm. EVIDENCE: There was evidence on the three service users files checked that in addition to social workers assessments the service undertake their own assessment of need prior to offering a place to a prospective service user. However on one service user’s file there was evidence that the issues identified in the pre-admission assessment were not adequately addressed. In the assessment undertaken by the service it was noted that there was a history that could possibly put other service users at risk. However despite serious issues of concern being identified in the assessment there was no evidence that they were given adequate consideration prior to admission. Aspray House DS0000044296.V328396.R01.S.doc Version 5.2 Page 9 The service was also in receipt of a mental health report detailing the behavioural problems that presented in a similar care setting as Aspray House. Again there was no evidence that the service gave this additional information adequate consideration. The risks the admission of this service user presented to other service users should have been very robustly assessed prior to any offer of placement to ensure the service had adequate resources in place to manage his care safely. The risk assessment for the service user was undertaken 13 days after admission and the strategy to address the concerns did not appear sufficiently robust to protect other service users. In admitting this service user without due regard to the identified concerns the service put the safety and wellbeing of all other service users at risk. The inspector reviewed the preadmission assessment of a second service user with dementia and noted there was insufficient information on her life history, this information is important particularly for service users with dementia and should form the basis of the care plan. It was noted on other records that staff were responsive to the cultural and religious needs of service users and appeared to be particularly supportive of relatives having difficulty adjusting to their changing role. Aspray House DS0000044296.V328396.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 10 Quality in this outcome area is adequate. However care planning requires further development. The service will also have to address how its processes fail to promote service users dignity and privacy. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three service users care plans were reviewed as part of the inspection process. All had current care plans in place. On the first care plan reviewed service users needs were identified and the level of support required was sufficiently detailed to guide staff to meet her needs. On the second care plan seen where nutrition was clearly a concern there was no dietary preferences noted. A problem was identified that the service user Aspray House DS0000044296.V328396.R01.S.doc Version 5.2 Page 11 tends to sit on other service users, however the intervention/strategy for staff was less than clear such as ensuring the service user lay down to sleep at night but staff were provided with no clear directions as to how best to encourage the service user to do so. Additionally the intervention also noted staff were to “get X to sit down to reduce pacing”, however particularly when there are barrier to communication the staff need very clear guidance on how to deliver this aspect of the care plan. It was noted on two occasions during the inspection that staffs handling of the service user was inappropriate. It is anticipated that clear guidelines/strategies in the care plan would prevent this. From reading the daily records it was noted staff maintain good detail on the activity of service users and the care delivered to them. However service users files containing confidential information are stored on open shelves in an unsecured nurses station therefore confidentially cannot be assured. It was noted as part of the admission process to Aspray House Service users are undressed and their body checked for bruising or marks. This is inappropriate. It is reasonable for staff to record marks or bruising following the normal delivery of personal care but as a procedure, which forms part of the admission process, it fails to promote service users dignity. At the time of the inspection it was positively noted that no service user in Aspray House had a pressure sore. It was noted that several service users had been provided with equipment necessary to promote tissue viability and prevent pressure sores. Promoting tissue viability was addressed in care plans, the inspector noted regularly reviewed assessment to establish a service users changing propensity to pressure sores. The inspector reviewed a randomly selected month of accident records to assess how the home responds to accidents and health crisis within the service. The quality of recording on the accident forms varied. In some there was a lack of detail about the injury sustained for example, one service user’s hand was “bruised and a bit bleeding” following an altercation. There was no record of the action taken in response to the occurrence. On the day of the inspection the inspector noted a service user’s hand extensively bruised with her finger and thumb swollen. Whilst the member of staff advised the inspector that he had noted the bruising the senior nurse on duty had not been advised of the marks. The manager advised that the service user had a history of bruising due to medication and skin type. This was confirmed on the service users care plan. However despite the propensity to bruise being an identified care need and noting a care plan was required there was none provided on the service users file. The manual handling assessment for the same service user was not fully completed such as there was no pressure sore risk score noted, the ability to co-operate or mobilise was not recorded and the assessment provided staff with no direction on moving and handling techniques for the tasks to be performed. Aspray House DS0000044296.V328396.R01.S.doc Version 5.2 Page 12 The service holds service users medications securely. It was noted on Medication Administration Records that gels and creams were ticked off rather than signed as administered. As a prescribed medication when administered by staff these need to be recorded as so. The inspector was pleased to note a well organised medication system however the following discrepancies were noted. Service User A - was prescribed Paracetamol one or two to be taken PRN and staff were signing when they administered one or two tablets. However an audit of the medication revealed that 21 tablets were missing. Service user B - was prescribed Zoplicone 7.5mgs 28 tablets were received, and on 10 occasions there were staff signatures to record the medication was administered however there was 19 tablets left in the box which means that one tablet was signed for but evidently not given. Service user C - there was evidence that Quetapine 25mgs was not consistently administered as prescribed. Service user D - there was no record that her medication Distador was received into the home. Aspray House DS0000044296.V328396.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is adequate. However the service will need to develop further the staffs role as enablers. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service has an activity co-ordinator in post who provides a range of appropriate group activities for service users. The activities are well advertised around the home. The inspectors observed a group quiz taking place and noted that the facilitator had engaged most service users who were evidently enjoying the activity and interaction. Inspection of care plans revealed a varied level of planning to meet service users social and leisure needs. On one service users care plan there were directions for staff to support the service users social needs such as staff reading the newspaper to the service user and encouraging her to join group activities. However on the second plan of care seen for a service user who needed a high level of support and assistance with all the activities of daily Aspray House DS0000044296.V328396.R01.S.doc Version 5.2 Page 14 living it was recorded that no arrangements were necessary to meet her social wellbeing. The inspectors observed a member of staff physically attempting bring a service user back into an activity she was clearly attempting to leave. The incident raised concern about the inappropriateness of the member of staff’s handling of the service user. It also demonstrated a failure to support a service user when she was clearly attempting to exercise choice and control over her own life by leaving the activity. It was noted that the particular group activity was not an inappropriate for the service user. Another service user told the inspectors “they (staff) treat you like a baby here”. When asked in what way the service user replied that staff don’t “let me do anything for myself”. During the inspection the inspector met three relatives at various points in the day. All were very positive about the home and the staff team that worked there. One relative told the inspector that her relative was admitted for respite care and that it was the family’s wish that the placement be made permanent, as there was “no where better to look after my mum”. The inspector also read records that evidenced staff were clearly listening to and acting on information provided by relatives advocating on behalf of service users. The inspectors observed lunchtime in the home, the meal was well presented and appeared nutritious and wholesome. Service users commented positively on the food provided. Aspray House DS0000044296.V328396.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is poor. The service has failed to demonstrate it took sufficient measures to protect service users or respond appropriately when abuse occurred. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector reviewed the services complaints procedure. At stage one of the complaints procedure it was noted that verbal complaints would be processed in the same manner as written complaints. That is “a written acknowledgement within 3 working days, and a full response within 3 working weeks”. There was evidence that complaints were recorded but the service’s response varied. One relative complained that “the staff were handling her mother too roughly and she was being hurt”. There was no evidence of a letter confirming receipt of the complaint, nor details evidencing any investigation. It was recorded that staff receiving the complaint offered an apology and assurances staff would be informed. However such allegations warrant further investigation. The inspector noted a record in the unit communication book about a relative complaining he had not been informed of an accident or hospital appointment. There was no record of this complaint in the service complaints log. The Aspray House DS0000044296.V328396.R01.S.doc Version 5.2 Page 16 inspector noted a further complaint that another relative made and there was evidence of a holding letter advising him that an investigation into his concerns was in progress, but there was no record of the outcome of the investigations. The inspector read the service’s adult protection procedure which details the action staff are to take in the event they witness or suspect abuse. It states suspicion of abuse must be reported to the manager or person in charge immediately and it will be logged with the Commission and the Safeguarding Adults team. During the course of the inspection the service was unable to provide evidence that it had responded appropriately to a situation in the home where a male service user had sexually abused female service users. From the incomplete records available there were 3 recorded instances where female service users were abused and the service failed to demonstrate robust and timely action to protect service users from further abuse. As noted earlier in the report the service failed to adequately consider the alleged perpetrator’s history of the sexual inappropriateness prior to admission. There was no evidence that either the Commission or the safeguarding adults team, nor service users relatives were notified of the abuse. It was also noted that the daily care records detailing the service users care for several days preceding his discharge were not presented for inspection. The inspector was advised these were missing. Aspray House DS0000044296.V328396.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome excellent. This judgement has been made using available evidence including a visit to this service. Aspray House is a comfortably decorated, well maintained clean service that is free from mal odours. EVIDENCE: The service users in Aspray House live in a well-maintained environment that is equipped with appropriate furnishings and fittings. The service uses CCTV in its entrance for security purposes. A report of a recent environmental health evidenced the service operates within local environmental health requirements. Aspray House is free from mal odours, with evidently clean, flooring, surfaces and furnishings throughout. The staff team are to be commended for their management of incontinence and the level of cleanliness throughout the home. The home’s laundry is sufficiently well equipped to deal with the demands of the service. Aspray House DS0000044296.V328396.R01.S.doc Version 5.2 Page 18 Aspray House DS0000044296.V328396.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. However the service will have to review it recruitment procedures. The service will also need to ensure all staff are skilled in meeting the specialist needs of service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Within the context of this report there have been several examples where the service has failed to demonstrate all staff are competent in meeting the specialist care needs of the service user groups. The inspector observed the support provided to one service user inappropriate and unsafe. The service user clearly did not wish to be seated at the dining table but her chair was in a position that effectively restrained her from getting up. Despite this she was struggling to rise and the member of staff was pushing her back down into the chair. The incident raised sufficient concern for the inspector to intervene and advise the member of staff of the inappropriateness of her actions. When the member of staff was advised that she could not restrict service users movements she was later seen by both inspectors to be trying to spoon feed the service user whilst she was mobilising. In feedback the manager advised that the service user should be provided with finger food to eat whilst she mobilised. Review of the service users care plan confirmed this. Aspray House DS0000044296.V328396.R01.S.doc Version 5.2 Page 20 Six training records were reviewed. Both mandatory and specific training had been undertaken in relevant areas of care practice. Training was delivered by various training agencies, however it was noted that all certificates of completion had been issued by the home. Where training has been completed it is expected that the body providing the training will supply the necessary evidence. Four staff files were randomly selected to test the recruitment processes in the home. The service’s policy on the retention of CRB disclosures needs to be amended to facilitate the holding of disclosures for the purpose of inspection by the Commission. One of the recruitment standards for the managing organisation advises that staff will need a CRB disclosure issued less than 6 months earlier and in the absence of this will the organisation apply for a disclosure. However CRB disclosures have no portability and employers must evidence that they have applied for disclosure as part of a safe recruitment. On one staff member’s file the employment history was unclear. Of the two references present, one was a character reference provided by a friend and the applicant’s relationship with the second referee was unknown. On another member of staff’s file there were character references only with no previous or current employer noted. No photographic identification was present as required. On a further file the service obtained two references from the same previous employer and despite an employment history indicating the applicant had previously worked in other care setting no relevant reference was requested. To ensure continuity of care the service has a responsibility to ensure staff appointed and hours of work are permitted by employment legislation. On one file there was evidence that employment must be authorised, but no evidence that authorisation had been sought. On another file as a student a member of staff was working far in excess of her permitted 21 hours per week. Aspray House DS0000044296.V328396.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. However the service will need to demonstrate notification of occurrences. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager of the service is appropriately experienced and qualified to manage Aspray House. She undertakes regular training and keeps herself up to date with new practices. The service provides staff with a variety of supervision, staff meet in teams where practice issues are discussed. Staff do not have documented one to one supervision every 8 weeks but there were sufficient structures in place to Aspray House DS0000044296.V328396.R01.S.doc Version 5.2 Page 22 evidence that the support, training and development provided for staff indicated an adequately supervised staff team. The Commission had previously been concerned about the lack of notifications it received in respect of the home. During the inspection the inspector seen a notification completed by one of the nurses to be forwarded to the Commission, which detailed unexplained bruises. However it had not been sent, the manager explained that this was because in her opinion the bruising was caused by medication and the service user’s skin integrity. It would be considered reasonable to forward the Commission the notification with this account detailed. Similarly, the service failed to notify the Commission of the sexual abuse of service users in the home. Aspray House DS0000044296.V328396.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 1 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 1 3 X X X X X X 4 STAFFING Standard No Score 27 2 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 1 X X X 3 x 3 Aspray House DS0000044296.V328396.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? no 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 OP3 Regulation 14 Requirement The registered manager must ensure that the service obtain a life history as part of the assessment for service users with dementia. The registered manager must ensure that information identified in the assessment process is appropriately considered and all service users are adequately assessed prior to admission. The registered manager must ensure service users records are maintained securely. The registered manager must ensure that care plans provide sufficient detail to guide staff in the delivery of care. The registered person must ensure that all processes in the home are underpinned by the need to promote service users dignity. The manager must ensure that all injuries are adequately recorded and prompt medical/nursing action is taken. Timescale for action 20/06/07 2 OP3 14 20/06/07 3 4 OP10 OP7 17 15 20/06/07 20/07/07 5 OP10 12 20/06/07 6 OP8 12 &13 20/06/07 Aspray House DS0000044296.V328396.R01.S.doc Version 5.2 Page 25 7 OP8 13 &15 8 OP9 13 9 OP9 13 10 OP12 12 &15 11 OP14 18 12 OP16 22 13 OP16 22 14 OP18 13 & 14 & 15 15 OP18 13 16 OP18 17 The registered manager must ensure that the moving and handling assessments for service users are complete with the outcome recorded on the service users care plan. The registered manager must ensure that service users have their medication administered as prescribed. The registered manager must ensure that a record is maintained of all medications being received, stored, administered and disposed of. The registered manager must ensure that the individual social and leisure needs of service users are planned for. The registered manager must ensure that staff receive training in how they can enable service users exercise more choice and control over their lives. The registered manager must ensure that all complaints are recorded in a central log and made available for inspection. The registered manager must ensure that all complaints received are fully investigated and responded to appropriately. The registered manager must ensure that the service responds appropriately to information that would indicate the need for additional safeguarding measures. The registered manager must ensure that the service takes prompt appropriate measures in response to actual or suspected abuse. The registered manager must ensure that all records as detailed in Schedules 3 and 4 of the Care Homes regulations 2001 are maintained and made DS0000044296.V328396.R01.S.doc 20/06/07 20/06/07 20/06/07 20/07/07 30/07/07 20/06/07 20/06/07 20/06/07 20/06/07 20/06/07 Aspray House Version 5.2 Page 26 available for inspection.18 17 OP27 18 The registered manager must evidence of further training in response to the skill gaps identified at this inspection. The registered manager must apply for another CRB disclosure for the member of staff identified at the inspection. The registered manager must demonstrate a robust recruitment by ensuring the requirements as detailed in schedule 2 of the CHR 2001 are met before staff are employed within the home. These must be maintained for the purpose of inspection. The registered manager must ensure the service notify the Commission without delay of matters as detailed in Regulation 37 of the Care Homes Regulations 2001. 20/07/07 18 OP29 19 20/06/07 19 OP29 19 20/06/07 20 OP32 37 20/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Aspray House DS0000044296.V328396.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ilford 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 Aspray House DS0000044296.V328396.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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