Care Home: Ashcroft

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What the care home does well Offering help, including written information and trial visits, to people choosing a care home. Providing residents with a clean, comfortable, homely environment. Making sure residents` personal and nursing care needs are met, and treating residents in a caring and respectful manner. Making sure the meals provided are varied and nutritious. Providing the home`s staff members with the training they need for their work with residents. Providing residents with an efficient laundry service. Consulting residents, their representatives and staff members about the quality of services provided and about the running of the home. The home is well managed and the manager makes sure she is readily available to residents or their representatives if they have any matters they wish to discuss. What has improved since the last inspection? Care planning has been made more person-centred, and monthly review meetings have been implemented. There have been improvements to the home`s environment. The lounge has been redecorated and had new wood flooring installed. Carpeting in communal areas has been replaced. A staff rest room has been created. The upper floor has been remodelled, which has made better use of space and created single, en-suite bedrooms from former shared bedrooms. They have addressed our previous recommendations, which included reviewing the homely remedies protocol regularly, improving their whistle blowing policy, and doing more to make sure all employer references for applicants are valid. What the care home could do better: Make sure any oxygen cylinders kept in residents` rooms are stored securely. This is important so the cylinders cannot fall over and potentially cause injury. Consider writing the content of care plans from the person`s point of view, to further enhance the person-centred approach the home is adopting. They are trying to offer residents more varied and personalised activities, but should also improve how activities undertaken are recorded. CARE HOMES FOR OLDER PEOPLE Ashcroft 48/50 London Lane Bromley Kent BR1 4HE Lead Inspector David Lacey Unannounced Inspection 4th November 2008 10:00 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 Ashcroft DS0000010126.V373047.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. Ashcroft DS0000010126.V373047.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashcroft Address 48/50 London Lane Bromley Kent BR1 4HE 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 8460 0424 020 8402 5640 suemaloney@care-providers.co.uk www.care-providers.co.uk Care Providers (UK) Limited Mrs Stella Martine Barnes Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Ashcroft DS0000010126.V373047.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing (CRH - N) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 22 Date of last inspection Brief Description of the Service: Ashcroft is an older, detached building, situated in a residential area of Bromley. It is conveniently placed for public transport, and is near to local shops and other facilities. The providers operate a separate domiciliary care agency. Ashcroft is registered to provide nursing care, which is provided over 24 hours with one nurse covering each shift. The registered manager is also a qualified nurse. The home provides accommodation on three floors, which can be reached via a passenger lift. Communal areas are on the ground floor. There is a garden with a patio at the rear. Some off-road parking is available at the front of the home. The fees for this home are £650 - £950 per week (this information given to CSCI in November 2008). Ashcroft DS0000010126.V373047.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two stars, which means that people using the service receive a good service. This key inspection included an unannounced visit to the care home. The inspector spoke with some of the residents and relatives, and met with the registered manager, deputy manager and members of staff on duty. The inspector toured the premises and observed some care practices. Documentation was sampled for inspection, such as care plans, medication records, staff recruitment files, and policies and procedures. Information from the homes Annual Quality Assurance Assessment (AQAA) has been used to inform the inspection process. This self-assessment document focuses on how outcomes are being met for people using the service. At the time of writing this report, the inspector was waiting to receive responses to our survey of some of the home’s residents. What the service does well: Offering help, including written information and trial visits, to people choosing a care home. Providing residents with a clean, comfortable, homely environment. Making sure residents personal and nursing care needs are met, and treating residents in a caring and respectful manner. Making sure the meals provided are varied and nutritious. Providing the homes staff members with the training they need for their work with residents. Providing residents with an efficient laundry service. Consulting residents, their representatives and staff members about the quality of services provided and about the running of the home. The home is well managed and the manager makes sure she is readily available to residents or their representatives if they have any matters they wish to discuss. Ashcroft DS0000010126.V373047.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ashcroft DS0000010126.V373047.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 Ashcroft DS0000010126.V373047.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): 1, 3, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective users of the service are offered enough information so they can make a choice about whether to move into the home. People are assessed before admission to ensure the home can meet their needs. The home does not offer intermediate care, thus standard 6 does not apply in this instance. EVIDENCE: The homes statement of purpose and service user guide meet standards and provide detailed information to help people decide whether to move into the home. The CSCI contact details in the statement of purpose need changing to reflect recent changes in our office address. The registered manager or her deputy carry out pre-admission assessments of prospective residents. Pre-admission assessments sampled for inspection were comprehensive and included information from different sources, such as the resident, their relatives, and professionals involved in their care. Assessments included people’s cultural and religious needs. Ashcroft DS0000010126.V373047.R01.S.doc Version 5.2 Page 9 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 good. This judgement has been made using available evidence including a visit to this service. Each person living in the home has a care plan, which offers guidance to staff on how to meet their assessed needs. People are treated with respect and their dignity and privacy are maintained. The health care needs of people using the service are met. Medicines administration is managed safely and effectively. EVIDENCE: Care plans selected for inspection had been drawn up based on the assessment of the individual residents needs. Plans had supporting risk assessments for mobility, falls, nutrition and pressure areas. Care plans were detailed, and had been regularly reviewed and updated. The home has been improving care plan documentation so it is more person-centred. The manager said this process had necessitated reflection on current nursing practice and making changes as needed. The manager explained about the monthly review meetings that have been implemented. These involve the resident, their family and their keyworker. The manager provides the resident and/or relatives with a summary of the care plan before the review takes place. This is good practice, as it means people can prepare for their review meetings in advance and know what Ashcroft DS0000010126.V373047.R01.S.doc Version 5.2 Page 10 questions they want to ask or what changes they would like made. To enhance the person-centred approach, the home may wish to consider making sure that care plans are written from the person’s point of view (recommendation). For example, an intervention had stated “Please help me by…” but staff had then written “[name] wants” or “[name] likes”, when it would be more appropriate to use the first person whenever possible. The inspector observed two residents being helped to mobilise by two carers with the use of hoists, and one resident being helped by a carer while using a walking frame. Carers used appropriate moving and handling practice, and throughout the process they provided the residents with verbal reassurance, encouragement and explanations about what they were doing. The residents’ dignity was maintained. A resident said that although she would much prefer to be able to move independently, the carers are good at helping her to move about the home. Residents were groomed well and were wearing suitable clothing for the time of year. People’s health care needs were being met. The home has a GP who visits the home each week and at other times as required. Residents said they were able to see the doctor if they needed. There were records of visits from other health and social care professionals, including the local nursing homes liaison team. A resident with high dependency needs was not able to speak with the inspector because of her condition but her relatives said they visit daily and were very happy with the standard of care being provided. They said that staff members are kind and helpful, and always quick to respond if they want to know anything or have any concerns. Medication is stored in a locked medicine trolley or in appropriate cabinets in a locked clinical room on an upper floor. Controlled drugs (CD) were being stored appropriately and the CD register was accurate. ‘Doom kits’ were available to destroy CDs no longer required. Internal and external medications were being stored separately. Some of the medications must not be stored at a temperature above 25 degrees. To make sure this maximum temperature is not exceeded, the home should make sure there is a room thermometer in the clinical room (recommendation). The temperature of the drugs refrigerator was being recorded daily. The sample of medicine administration records seen showed these had been completed accurately. There were no residents self-administering their medicines. A resident said she had been offered the opportunity to manage her medication but had declined, as she prefers staff to do it – “I find it too confusing”. Her choice in this respect had been recorded. Records of receipt and disposal of medicines were good. The home had a comprehensive medication policy and procedures, as well as guidance in medicines administration published by the Nursing and Midwifery Council. It was evident the registered manager audits medication administration regularly. The homely remedies protocol had been reviewed. Ashcroft DS0000010126.V373047.R01.S.doc Version 5.2 Page 11 Two residents were being prescribed oxygen, which they were using in oxygen concentrators. The residents said they needed to use the concentrators all the time, including at night. They are made as comfortable as possible to help them get adequate rest at night. The cylinders were being stored in their bedrooms, and this has been commented on later in this report under standard 38. Standard 11 was not assessed on this occasion but it was positively noted that Ashcroft is shortly to begin working with a local hospice to develop the Gold Standards Framework for end of life care within the home. Ashcroft DS0000010126.V373047.R01.S.doc Version 5.2 Page 12 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 good. This judgement has been made using available evidence including a visit to this service. People living in the home benefit from being able to choose to take part in the planned activities that are made available. People using the service choose how they spend their time and are supported to maintain contact with their families and friends, if this is their choice. The home offers its residents a balanced and nutritious diet, including choices about what to eat. EVIDENCE: We carried out an annual review of this care home in December 2007. The only aspect about which we received some suggestions for improvement was in the provision of more varied and personalised activities. The homes AQAA set out the improvements already made in this respect and the new developments planned for the following year. Residents can choose whether to take part in different planned activities. All care staff are involved in facilitating activities, which include bingo, quizzes, singing, quizzes and reminiscence. Large print books are available. The notice board in the main hallway gives details of planned events. The care documentation sampled for inspection had records of the residents’ daily activities. However, many of these records read like daily notes, for example “appears bright today, visited by relatives”, rather than recording activities that people had taken part in (recommendation). Ashcroft DS0000010126.V373047.R01.S.doc Version 5.2 Page 13 Peoples preferred lifestyles are respected. For example, residents can choose how they spend their time and can get up or retire to bed whatever time they wish. Residents can bring in their own personal possessions to make their bedrooms more personal and homely, and visitors are welcomed at any reasonable time. The food served at lunch was well presented and it was evident that residents had been able to choose what they ate. Carers offered sensitive assistance with feeding as required. The home’s layout means there is no separate dining room. Thus, most residents took their lunch at their chairs in the lounge, using individual tables, though there was a larger table being used by a small group of residents. Residents who spoke with the inspector made positive comments both about their lunch and also about other meals served at the home. Ashcroft DS0000010126.V373047.R01.S.doc Version 5.2 Page 14 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 good. This judgement has been made using available evidence including a visit to this service. Residents and their representatives are offered the information they need to be able to make a complaint. The home takes any concerns or complaints seriously, and follows its procedures when investigating and responding to them. Training is provided for staff so they know about safeguarding the people in their care, including following the relevant procedures. EVIDENCE: A copy of the homes complaints procedure is displayed in the entrance hall and a copy is also provided in the guide given to each resident. During the inspection visit, residents said they would speak to their relatives, a staff member or the manager if they were not happy about something. The homes complaints file was seen and showed that, since the previous inspection, four complaints had been received by the home. Records had been kept of the actions taken in respect of those complaints. The commission has not received any complaints or concerns about this care home. The inspector saw examples throughout the day of positive, relaxed interactions between residents and staff. A copy of the local councils safeguarding guidance was available, as well as the homes safeguarding policies and procedures. Staff confirmed they receive relevant training, including how to recognise and different types of abuse. The home’s whistle blowing policy had been reviewed. Ashcroft DS0000010126.V373047.R01.S.doc Version 5.2 Page 15 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): 19, 22, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a homely environment, which is clean and safe, and benefit from the recent improvements made to the home. Staff members know about basic infection control practices and are trained to use the procedures and facilities that are in place to prevent infection. EVIDENCE: The home was clean, tidy, and no offensive odours were evident. The home was being kept at a comfortable temperature. The home appeared well maintained, and the provider employs a maintenance person to whom the staff report any items needing attention. Since our last inspection, the provider has made improvements to the homes environment. The lounge has been redecorated and had new wood flooring installed. Carpeting in communal areas has been replaced. A staff rest room has been created. The upper floor has been remodelled, which has made Ashcroft DS0000010126.V373047.R01.S.doc Version 5.2 Page 16 better use of space and created single, en-suite bedrooms from former shared bedrooms. The extension at the back of the building that was being planned at our last inspection had not been built, and it was understood revised plans were now being made for extending the home. The home has a passenger lift to access all floors. Equipment to assist residents to mobilise includes three hoists (standing, full body and multi-lift). Grab rails are fitted in all corridors and toilets. Corridors are large enough for wheelchairs. Pressure-relieving mattresses and cushions were available for those residents assessed as needing them. The emergency call system is readily accessible to residents and operates throughout the home. Some of the residents had bedrails and risk assessments were seen for these. Padded sides are used with bedrails to enhance residents safety. The home’s laundry is sited in the basement. Its washing machines use the Otex system, which means there is no need to sluice at high temperatures. The laundry was well organised, with a full-time laundry assistant on duty during the week and a part-time assistant at the weekends. The linen cupboards on each floor were well stocked. The inspector examined several sheets at random and found them to be in good condition. The hot water outlets tested during the inspection visit were at a satisfactory temperature. There are sufficient sluices and disinfectors in the home, and this equipment was in good order. Infection control procedures are in place and staff members spoken with confirmed they had completed relevant training. The registered manager carries out regular infection control audits. Ashcroft DS0000010126.V373047.R01.S.doc Version 5.2 Page 17 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): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home makes sure there are enough suitably qualified staff on duty to meet residents needs. The training offered to staff is relevant to their work in the home, and a high proportion of care staff members have achieved NVQ level 2 or higher. People living in the home benefit from the robust staff recruitment procedures. EVIDENCE: On the day of the inspection visit, the number and skill mix of staff working in the home was appropriate to meet the needs of the twenty people in residence. Staffing rotas seen showed that staffing levels and mix had been maintained, including staffing for cleaning, laundry and catering. There is a settled team with low turnover of staff. Staff members were seen to work well together as a team, and those spoken with confirmed there was usually a good team spirit in the home. The inspector selected three staff recruitment files for examination. The files showed that sound recruitment procedures were in operation and that all required information was obtained about applicants before they started work in the home. The authenticity of references is checked. Criminal Records Bureau (CRB) disclosures are stored separately, and two of the staff files had a corresponding disclosure in the separate CRB file. The third file had a POVA First check and evidence of a CRB application in progress. The manager confirmed this staff member only works with someone else supervising. Staff Ashcroft DS0000010126.V373047.R01.S.doc Version 5.2 Page 18 members who spoke with the inspector confirmed they had applied and been interviewed for their posts. They had been required to provide references and have a CRB disclosure through the provider. The staff training records showed that staff members have regular updates of mandatory training after completing induction. Feedback during the inspection visit from staff members about the work they did and the on going support they received was positive. The inspector asked staff about specific areas, including residents care, health and safety, staff training and supervision. The staff possessed a range of knowledge and skills, and had undertaken various types of training. Their training aimed to help them meet residents needs. The home partners with the Bromley training consortium and thus staff have access to their training events and opportunities. The provider has held Investor in People status since January 2006, which is also a positive indicator that training and development for staff is good. Nearly all care staff had attained NVQ level 2, and some had either begun or completed NVQ level 3. The homes commitment to supporting its staff to attain NVQs in care is very good. Ashcroft DS0000010126.V373047.R01.S.doc Version 5.2 Page 19 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): 31, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their representatives can be assured the registered manager has the skills and experience needed to run the care home well. There is an open style of management, with staff and residents encouraged to contribute their views about the running of the home. There are effective quality assurance strategies in place. The provider is on the premises on a daily basis, and also carries out formal monitoring visits. The home promotes the health and safety of its residents, staff and visitors. EVIDENCE: The registered manager is a qualified nurse, who is experienced in the care of older people and who encourages a person-centred approach to care. She holds relevant management qualifications and undertakes continuous professional development, for example, through her work as the present chair Ashcroft DS0000010126.V373047.R01.S.doc Version 5.2 Page 20 of the local care home managers’ association. The manager is also an NVQ assessor, which enhances the homes ability to ensure its care staff complete NVQ programmes. There were positive comments from residents and staff about the managers approach to running the home. These showed that the manager has good people skills and communicates a clear sense of direction. Staff said they were supported by their manager and were able to meet with her regularly. The home had scheduled two relatives meetings this year (May and October) but no relatives had turned up for either meeting. The notice board in the homes reception area had a copy of the last commission inspection report and a summary of the results of a satisfaction survey carried out by the home in September/October 2008. There were other quality assurance strategies in place, including a quality management system. Specific audits carried out regularly by the registered manager include infection control, medication, wheelchair maintenance, care plans, and accidents. The home sent us their AQAA when we asked for it. It was clear and detailed, giving the information we asked for. We have received reports from the provider of monitoring visits to the home, and we have been notified without delay of events regarding residents health and welfare. The inspector examined a sample of records showing how residents money is managed. Monies are stored in a locked safe, in individual wallets, and each transaction had been clearly identified and signed for by two people. In each case, the amount of money held matched the recorded amount. Receipts had been retained, and receipts for deposits of money given to the resident or their representative as appropriate. Residents are invoiced for additional charges, such as hairdressing or newspapers. A selection of health and safety documentation was examined and found to be up to date and within the appropriate timeframes. As also noted elsewhere in this report, the inspector saw staff using hoists correctly. A fire risk assessment had been completed, and fire extinguishers and emergency lighting had been checked and serviced appropriately. As noted under standard 9, two residents had oxygen cylinders being stored in their bedrooms. When drawn to her attention, the manager arranged immediately for the necessary hazard signs to be displayed and confirmed she would make sure that the cylinders would not be stored in the residents’ rooms until they can be secured so they cannot fall over (requirement). Ashcroft DS0000010126.V373047.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 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 3 X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Ashcroft DS0000010126.V373047.R01.S.doc Version 5.2 Page 22 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 OP38 Regulation 13(4) Requirement The registered person must ensure that any oxygen cylinders kept in residents’ rooms are stored securely. This is important so the cylinders cannot fall over and potentially cause injury. Timescale for action 30/11/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations The registered person consider making sure that care plans are written from the person’s point of view, to enhance the person-centred approach the home is adopting. The registered person should make sure there is a room thermometer in the clinical room, to ensure the temperature does not get too high for the safe storage of medicines. The registered person should ensure the recording of activities undertaken by residents is improved. 2 OP9 3 OP12 Ashcroft DS0000010126.V373047.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Ashcroft DS0000010126.V373047.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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