Inspection on 24/01/07 for The Ashurst

This inspection was carried out on 24th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Ashurst 27/06/07

The Ashurst 19/10/05

The Ashurst 06/04/05

The Ashurst 17/11/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Ashurst, The 1 Kirkley Cliff Lowestoft Suffolk NR33 0BY Lead Inspector John Goodship Key Unannounced Inspection 24th January 2007 10:10 Ashurst, The DS0000059596.V327469.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 Ashurst, The DS0000059596.V327469.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. Ashurst, The DS0000059596.V327469.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashurst, The Address 1 Kirkley Cliff Lowestoft Suffolk NR33 0BY 01502 519222 01502 537406 ashurstcarehome@btconnect.com 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) Mr A T Wight Mrs Joanna Louise Jay, Mr Martin Edward Jay Mrs Gillian Elaine Murrell Care Home 19 Category(ies) of Learning disability (19), Learning disability over registration, with number 65 years of age (7) of places Ashurst, The DS0000059596.V327469.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 Five persons, over the age of 65, whose names were made known to the Commission for Social Care Inspection in November 2004. 19th October 2005 Date of last inspection Brief Description of the Service: The Ashurst is a residential care home for 19 people with learning disabilities. The home is located in a residential area of Kirkley south of the coastal town of Lowestoft and is close to the beach, pier, marina, local shops, churches and amenities. The accommodation spans three floors served by a shaft lift. There is one double bedroom, the remaining are single. All bedrooms have a wash hand basin and eight bedrooms have en-suite facilities. The front windows of the home on the first and second floors offer excellent views of the North Sea. The home offers three communal rooms on the ground floor where service users meet friends and relatives, participate in crafts, hobbies or board games or watch television. There is also a small room for private meetings. Ashurst, The DS0000059596.V327469.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a key unannounced inspection and was the first visit by the Commission for twelve months. The manager was on sick leave, but one of the directors who acts as the home’s administrator was present throughout. The visit took place during the daytime when some of the residents were there and others arrived later from outside activities. The inspector was able to talk to several of them and their comments are reflected in the report. Prior to the visit, a questionnaire was sent to residents and to relatives to ask their views of the home. Ten residents replied with help from staff, and seven relatives replied. Their written comments are also incorporated in the report. What the service does well: What has improved since the last inspection? What they could do better: The Statement of Purpose and the Service Users’ Guide must be improved to contain all the items of information required by the Regulations, and be available in a format suitable for the residents to understand. The daily care records should show a person-centred approach to the entries, to identify positive features not just the absence of problems. Care plans must Ashurst, The DS0000059596.V327469.R01.S.doc Version 5.2 Page 6 identify health and personal care issues with strategies for dealing with them. Personal hygiene records must be kept up-to-date. The frequency of bed linen changes should be reviewed. All changes in prescribed medication must be recorded on the medicine administration record sheet. No medication must be allowed to run out. The policy on the protection of vulnerable adults must be updated in line with the current county policy. Records must be kept of the training of staff in protection. An accessible training plan for staff must be available, showing clearly what training has been programmed and what has been successfully completed. Although there was evidence that health and safety issues were monitored, some of them were not up-to-date. These records must not be dependent on the presence of one person. A back-up system must be organised. 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. Ashurst, The DS0000059596.V327469.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 Ashurst, The DS0000059596.V327469.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): 1,2,4,5. Quality in this outcome area is adequate. Prospective residents and their representatives cannot easily find the information they need as it is not in an organised or user-friendly format. Prospective residents will have their needs assessed and have the opportunity to try the home out. Residents or their representatives cannot expect to receive an individual contract which sets out the requirements of the Care Homes Regulations. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were 18 people in residence on the day of the inspection. An 85 year old resident had moved to a nursing home the week prior to the inspection because their needs had changed. This had left a vacancy in a shared room which the director said would not be filled. The inspector was told that staff had visited this resident, and that the manager had brought the person back to lunch last week. Two residents who were sharing with each other in two rooms, one a bedroom and one a sitting room, had changed their arrangements so that each now had a separate bedroom. Ashurst, The DS0000059596.V327469.R01.S.doc Version 5.2 Page 9 There had been one new admission since the last inspection. This person had been to look at the home according to the director. However there was no record in their file of this visit. Nor was the director able to produce a preadmission assessment for this person, although there was a comprehensive assessment by the social worker, and an assessment from the short-term care placement prior to their move to The Ashurst. Admission records examined on previous inspections had evidenced comprehensive assessments by the manager. The director suggested that the manager had not yet filed the assessment. The director described another referral. This person had been offered a choice of two homes, had tried staying in both but chose the other one. The Statement of Purpose contained nearly all the information required by the Regulations. The inspector was told that it was being updated. The Service Users’ Guide was seen. It was not clear where the Statement of Purpose ended and the Service Users’ Guide began as they were all in the same file. Most of the information required was present over both documents but was not organised in an easily understandable presentation or format. Neither document contained the fee information or an example of a contract/terms and conditions of residence that is required. There was a letter in one resident’s file from Suffolk County Council to their relative detailing the resident’s contribution to the care fees. There were now four residents over 65 years of age. This was well within the home’s registration category which permitted up to seven residents over 65 years of age. This category had been requested by the home in 2006 in order to allow the home to continue to care for their residents as they aged. Ashurst, The DS0000059596.V327469.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9. Quality in this outcome area is good. Residents can be assured that their changing needs will be reviewed regularly with them. They are encouraged to have as much independence as is consistent with their abilities, within a risk-assessed framework. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans for the most recent admission and for a longer-term resident were examined. One was created shortly after their admission. It was reviewed six months later, with the resident and the funder invited. The other had been reviewed in February 2006. It was due for the annual review. There were guidelines for staff on helping one person with their self-control, and there was a good description of what triggered episodes of what staff had described as “bad temper” and how to avoid the situations arising, or how to Ashurst, The DS0000059596.V327469.R01.S.doc Version 5.2 Page 11 de-escalate when it happened. There were other risk assessments in care plans covering internal and outside situations. The plans covered all appropriate areas of daily living including day activities, preferences, and health care. There was a personal hygiene record but the entries were not up-to-date. It was noted that the daily record for the home contained the phrase “no problems” many times. There was not always a positive view of each resident’s day, with staff taking a problem-centred approach rather than a personcentred approach. Examples were seen of residents taking decisions about their lives, such as going out to Norwich for the day on their own, choosing not to go to their day activity, choosing what clothes to wear each day. Ashurst, The DS0000059596.V327469.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,17. Quality in this outcome area is good. Residents are supported to take part in a variety of activities within the local community. They are helped to maintain family links, and their wishes are respected. Residents are supported to eat well both inside and outside the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Thirteen of the residents had some planned day centre activity on some days of the week. Five residents had no place at a centre, but the home supported them to do what they wished as far as possible. External day activities included a manufacturing and packing centre, a skills centre for cookery, computing and other course leading to a certificate, a furniture restoration project, helping in a nearby charity shop, and one resident was on a course at Lowestoft College. Ashurst, The DS0000059596.V327469.R01.S.doc Version 5.2 Page 13 The home was concerned that the number of days offered to some of the residents were reducing. To help fill a gap, the home had started a day centre for two hours a week in a local church hall. There had been requests from social workers to take other people in this facility but the home had not yet agreed how this would be funded. One resident had expressed a wish to stop going to one of the centres. The funder was investigating alternatives. Another resident was anxious that their work at the charity shop was finishing. They described what they did, and who was helping them find another job. One resident over 65 years old returned during the visit from a trip to Norwich on his own. They enjoyed these trips and described where they had bought their lunch “at a very good price.” A relative had commented that they had seen a resident’s hair being dried in the lounge and thought this was undignified. The director thought this may have been the very elderly resident who had since transferred to a nursing home. This person had liked to be in the lounge and because of the difficulty of moving them staff had recently been bringing them into the lounge after washing their hair. In the pre-inspection questionnaire, all residents who replied said that they always or usually liked the meals. During the week, the main meal was taken in the evening. During the inspection, those residents in the house had a snack lunch in the dining room, which they said they were enjoying. Relatives who replied to the pre-inspection questionnaire all said that the home kept them informed about their relative. Ashurst, The DS0000059596.V327469.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20. Quality in this outcome area is adequate. Residents’ health and personal care needs are identified and they receive appropriate support, according to residents’ and staff comments. However the record of this support is incomplete so that the home cannot evidence what is actually given. Residents cannot be assured that their prescribed medication will be available for administration at all times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each resident had a personal hygiene record. In the two care plans examined, this record was incomplete. In one case it recorded that the resident was bathed once a month, and their hair was washed monthly. Staff said this was wrong as these aspects of personal hygiene were done much more frequently. However there was nothing in the daily record to confirm this. One relative had commented that their relative’s hair should be washed more often, so the home was therefore unable to evidence frequency. Ashurst, The DS0000059596.V327469.R01.S.doc Version 5.2 Page 15 Care plans did show contacts with NHS services. The community nurse was visiting two residents regularly to advise on their eating problems. The nurse was also helping staff to persuade a resident to have their hair cut. Staff described the continence problem of one resident. There was no mention of this in their care plan. The room of one resident had a faint unpleasant odour. This was said to be due to that person’s night incontinence. There was no mention of this issue in their care plan, where ways of reducing the problem should have been set out. One resident had been referred to the community team for assessment, as the home believed they were beginning to exhibit symptoms of dementia. The medication records and storage were checked. All drugs had been signed for, apart from the administration of a cream on one day. The drug “Flupentixol” had ran out for one resident on 19 January and had still not been replaced by the time of the inspection on 24 January. The inspector was told that the GP had increased the dosage recently, causing the supply to run out before the next normal delivery from the supplier, but there was no record of this change on the Medicine Administration Record. When pointed out, the director immediately chased the supplier who promised to deliver it later that day. Ashurst, The DS0000059596.V327469.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. Quality in this outcome area is adequate. Residents can be assured that their views will be heard and acted on. The home cannot assure residents that they will be fully protected from abuse as it cannot evidence up-to-date procedures or records of staff training in this topic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints policy for the home met the standard. The complaints log showed that no complaints had been received since the previous inspection. All those who responded to the relatives’ questionnaire stated they had never needed to make a complaint. Residents said that they would always be happy to raise any matters with the manager. The policy and procedure for the protection of vulnerable adults was not up-to date in line with Suffolk County Council protocol. There was no clear guidance for staff on the appropriate action to take when allegations were observed or reported. There was no evidence that staff had received any training recently in the recognition of abuse. However when questioned staff showed that they did understand the different kinds of abuse and knew what their responsibilities were. Ashurst, The DS0000059596.V327469.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): 24,25,30. Quality in this outcome area is good. Residents are living in a safe environment except for the food hygiene risk in the top floor kitchenette. Bedrooms are well furnished and individually decorated to reflect the interests of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The office had been moved from the front of the house to the small room behind the smaller lounge, with its entrance onto the hall. Its previous room was being turned into another resident’s room. This would replace the one place which the home had given up in a shared room. The opening that had been made last year from the dining room had still not been finished off, with the wood unpainted and the rough sides not plastered. The room opposite, looking out to the front, was being prepared as a multipurpose room, principally for residents, but also for staff meetings and Ashurst, The DS0000059596.V327469.R01.S.doc Version 5.2 Page 18 training, and for meetings with relatives. A double doorway had been made from this room to allow light from the bay window to lighten the dining room. The home had an on-going programme of redecoration which was being undertaken by the maintenance man. The room of one resident had a faint unpleasant odour. This was said to be due to that person’s night incontinence. There was no mention of this issue in their care plan, where ways of reducing the problem should have been explored. No other unpleasant odours were present throughout the home. Rooms were well furnished and showed individuality in the décor. One resident had a large collection of model cars and trains, including a track layout on the table. There was a kitchenette on the top floor which was mostly used by one resident but was accessible to others on that floor. It contained a fridge with a freezer compartment which was completely frozen up. The fridge contained an open pack of turkey slices, undated and uncovered. There was a jug of milk for one resident, and two kinds of spread for two residents. The inspector discussed with staff the need to allow appropriate independence for residents while maintaining food hygiene requirements for their safety. A relative had commented that they thought that bed linen should be changed more regularly. The director confirmed that bed linen was changed fortnightly. He was asked to review that policy to ensure dignity and hygiene. Ashurst, The DS0000059596.V327469.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): 32,34,35,36. Quality in this outcome area is adequate. Residents can be assured that they will be supported by staff who have been properly recruited and are regularly supervised, and who have achieved qualifications and undertaken some specialist training. However they cannot be assured that all staff will have undertaken training in the key mandatory topics as records are not complete. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Only one person had joined the staff since the previous inspection. This demonstrated the stability of the staffing. Their file was examined. It contained the required identification documents, employment history and two references. The Criminal Records Bureau Disclosure certificate was received five days before the person started work. There was also confirmation that they had undertaken medication training. The manager had developed a contract for supervision which was good practice. Due to the absence of the manager, records of supervision sessions Ashurst, The DS0000059596.V327469.R01.S.doc Version 5.2 Page 20 were not available to be examined. However staff confirmed to the inspector that these sessions took place on a regular basis. The state of staff training in the Certificate in dementia awareness was examined. All care staff had completed or were shortly to complete the course. However, some were waiting for their units to be marked, so not all certificates were yet available. There were nine staff who had completed NVQ Level 2 and two had completed Level 3. There was no training plan for the year available to examine, nor a clear record of all training in the past year, although there were some certificates on individual files. It was not possible therefore to check how many and how often staff were updated in moving and handling, food hygiene, and other mandatory topics. There were three staff on during the day, with one person sleeping in at night. In addition, the home had been funded to provide an additional four hours care per week to support three residents on the days they did not attend a day centre. Ashurst, The DS0000059596.V327469.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): 37,39,41,42. Quality in this outcome area is adequate. Service users can be assured that the home is well run, with safety systems in place, and opportunities for their views to be heard. However, the home’s records cannot substantiate that all safety checks have been done. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager was responsible for the management of care, supported by one of the owners who undertook administrative, maintenance and budgeting responsibilities. The home had a full-time maintenance person. Ashurst, The DS0000059596.V327469.R01.S.doc Version 5.2 Page 22 Staff confirmed that staff meetings were held, but the last set of minutes available was for October 2005. The inspector was told that formal residents’ meetings were not held, as the manager found it much more productive to chat to them in the dining room during the evening meal, or even better to talk to them individually. The home had been visited by the local Fire Prevention Officer in July 2006. He had required the home to keep a fire log. The Fire Log was examined. It contained the fire risk assessment. This had last been reviewed in August 2005, so it was overdue for review. Fire alarm tests were logged up till 29/11/06, fire equipment checks until 11/12/06 and weekly tests until 11/12/06. A member of staff was designated as health and safety officer and responsible for these checks. It was suggested to the inspector that this person might have been absent for a period. The home should have a second person as back-up if there is any interruption in the checks. The accident records were examined. There had been only two in 2006, one concerning the older resident who had moved into nursing care, and one resident had turned their ankle when out walking. Records of hot water temperatures were kept. However there was no record after 11/12/06. The home was in the process of changing the previous office accommodation into a new resident’s room, and a small sitting room/meeting room. Food hygiene practices were not sufficient in the top floor kitchenette as described under “Environment”. A relative had commented on the safety of staff doing the ironing in the lounge. The director felt that this was a homely touch, but accepted that there were hazards involved regarding the hot iron and a trailing lead. They were asked to risk assess this matter and find an alternative location if indicated by the assessment. Ashurst, The DS0000059596.V327469.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 2 3 3 4 3 5 2 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 3 25 3 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 3 X 2 2 x Ashurst, The DS0000059596.V327469.R01.S.doc Version 5.2 Page 24 NO 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 YA5 Regulation 5(1) Requirement The service users’ guide must contain the information on terms and conditions, and fees, detailed in this regulation. All changes in prescribed medication must be recorded on the Medicine Administration record sheet to ensure that residents are medicated safely. Medication prescribed for each resident must always be in stock to prevent interruption to a resident’s treatment. The home’s policy on the protection of vulnerable adults must be updated in line with the current County Council policy, giving clear guidance on action which must be taken by staff and management. The home must be kept free from offensive odours. The food hygiene arrangements in the top floor kitchen fridge must be risk assessed in accordance with DS0000059596.V327469.R01.S.doc Timescale for action 01/04/07 2 YA20 13(2) 01/03/07 3 YA20 13(2) 01/03/07 4 YA23 12(1)(a) 01/03/07 5 6 YA30 YA30 16(2)(k) 16(2)(j) 01/03/07 01/03/07 Ashurst, The Version 5.2 Page 25 7 8 YA41 YA42 environmental health regulations. 17(3) All records in respect of each resident must be kept up-todate. 12(4),23(4)(c) All records in respect of the fire log and water temperature log must be upto-date. 01/03/07 01/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 7 8 Refer to Standard YA1 YA2 YA6 YA19 YA23 YA30 YA35 YA42 Good Practice Recommendations The service users’ guide should be clearly written and in a format suitable for prospective residents to understand. Pre-admission assessments should be available in each resident’s file. The daily record of each resident should demonstrate a person-centred approach to their care. Personal care records should be up-to-date with regular audits to ensure proper completion. The training of staff on the protection of vulnerable adults should be recorded. The frequency of bed linen changes should be reviewed to ensure good hygiene and residents’ dignity. The manager should develop a plan of training which can be assessed and audited against completion. The practice of staff doing the ironing in the lounge should be risk assessed for safety. Ashurst, The DS0000059596.V327469.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Ashurst, The DS0000059596.V327469.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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