Care Home: Ashwood

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What the care home does well The level of personal information and assessment of residents` needs is well recorded and used to compile relevant care plans that are regularly reviewed. Staff are knowledgeable about residents` individual preferences. Complaints and concerns are taken seriously and fully investigated. Complainants receive a written response containing the outcome of the investigation within a given time scale. Although the building is over twenty years old and some of the fabric of it is worn and `tired` staff work very hard to maintain a clean and homely environment. What has improved since the last inspection? There were no requirements left at the last key inspection. The service has recently appointed an activities co-ordinator who is in the process of collating information about what activities and outings the residents would enjoy. They have commenced a weekly activity programme that is open to any resident who wishes to participate. There has been some ongoing redecoration in the home including personalising some of the residents` bathrooms at their request. What the care home could do better: The daily records were generally informative but lacked details about whether residents had had baths or showers according to their stated preference. Risk assessments need to be completed to cover a resident`s choice of behaviour that could potentially put them at risk. All refrigerators in the home should have regular temperature checks to ensure that they are functioning correctly. All evidence of the recruitment checks undertaken on new staff should be retained in their files. The numbers of staff with NVQ level 2 qualification or above should be increased to meet the recommended percentage. The system for managing residents` personal monies needs to be reviewed and made more robust to protect residents` financial interests and the staff who manage them. CARE HOMES FOR OLDER PEOPLE Ashwood New Road Ware Hertfordshire SG12 7BY Lead Inspector Jane Offord Unannounced Inspection 3rd April 2008 09:30 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 Ashwood DS0000019273.V361837.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. Ashwood DS0000019273.V361837.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashwood Address New Road Ware Hertfordshire SG12 7BY 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) 01920 468966 01920 485188 www.runwoodhomecare.com Runwood Homes Plc Christine Chambers Care Home 64 Category(ies) of Dementia - over 65 years of age (64), Old age, registration, with number not falling within any other category (64), of places Physical disability over 65 years of age (64) Ashwood DS0000019273.V361837.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Manager must successfully complete the Registered Managers Award, followed by NVQ Level 4 in Care by 31.01.07. 3rd April 2007 Date of last inspection Brief Description of the Service: Ashwood is a purpose built home situated near the centre of Ware giving access to local amenities and transport. The home is owned and managed by Runwood Homes PLC. The accommodation is made up of six bungalows that are internally linked. Each bungalow is self-contained and includes a lounge and kitchen/diner. The main entrance to the home leads into a communal lounge area and conservatory. There is a kitchen and laundry that serve the whole complex. The home offers accommodation to sixty-four residents in single rooms with en suite facilities. Two rooms are retained for respite care and short stay admissions. There are a number of pleasant courtyards and mature gardens around the home with level access from the bungalows. Fees for the home range between £407.89 and £625.00 per week. They do not include the cost of hairdressing, toiletries, chiropody, newspapers, clothing or a private telephone line. The home does have a payphone for the use of residents. Ashwood DS0000019273.V361837.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 star. This means that people who use this service experience good quality outcomes. This key unannounced inspection looking at the core standards for care of older people took place on a weekday between 9.30 and 17.00. The deputy manager and area manager for Runwood Homes PLC were present throughout the day and assisted with the inspection process by providing documents and information. This report has been compiled using information available prior to the inspection, including the annual quality assurance assessment (AQAA) that is a self-assessment document completed by the service, and evidence found on the day of inspection. During the day a tour of all the bungalows was undertaken with the deputy manager but most areas were revisited later during the inspection. The personal files and care plans of five residents were seen as well as four files of newly recruited staff members. Other documents inspected included the local policy folder, the complaints log, the fire log, the duty rotas and some service certificates. A number of residents, visitors and staff were spoken with and care practice was observed. Part of a medication administration round was followed and the records of residents’ personal finances were seen. On the day of inspection the home was clean and tidy with no unpleasant odours. Residents were spending time in all areas of the home and looked relaxed and comfortable. Visitors came and went during the day and were welcomed by staff. The lunchtime meal was seen served and looked and smelled appetising. Interactions between staff and residents were friendly and caring. People spoken with said they were happy in the home and ‘felt safe’. What the service does well: The level of personal information and assessment of residents’ needs is well recorded and used to compile relevant care plans that are regularly reviewed. Staff are knowledgeable about residents’ individual preferences. Complaints and concerns are taken seriously and fully investigated. Complainants receive a written response containing the outcome of the investigation within a given time scale. Although the building is over twenty years old and some of the fabric of it is worn and ‘tired’ staff work very hard to maintain a clean and homely environment. Ashwood DS0000019273.V361837.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. Ashwood DS0000019273.V361837.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 Ashwood DS0000019273.V361837.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. People who use this service can expect to have adequate information available to make an informed choice about admission and have a pre-admission assessment of need undertaken. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has an up to date and comprehensive statement of purpose and service users’ guide that are both available to prospective residents and their representatives. People considering moving into Ashwood are invited to visit the home and meet the staff. Two people enquiring about admission were shown around the home by one of the staff on the day of inspection. New residents have a six-week trial period in the home and the decision to become a permanent resident is taken during a review meeting held at the end of the six weeks. Ashwood DS0000019273.V361837.R01.S.doc Version 5.2 Page 9 The home has two rooms used for respite care and a number of people are regularly booked in for a short visit, this means that residents and staff get to know short stay people and they know the home and the routines. The files of five residents who were admitted within the last year were seen and each one contained a pre-admission assessment based on the activities of daily living (ADLs). The assessment included a mental test score and covered areas of need such as mobility, any aids the person needed, past medical history and any known allergies. Any health care professionals involved with the person were recorded. This service does not offer intermediate care. Ashwood DS0000019273.V361837.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 good. People who use this service can expect to have their health needs met and a care plan in place to help staff support them, as they would wish. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All the files seen contained an assessment of need on admission to the home that covered areas of physical and mental health and interests, hobbies and social needs too. There was evidence that the needs assessment was reviewed monthly to ensure that any changes were noted and added to the care plan. The care plans in the files were developed from the assessment of need and further risk assessments for specific areas of care such as tissue viability, falls prevention and nutrition. Any risk assessment that gave a resident a score that showed a degree of risk had an appropriate care plan intervention to show how the risk was to be managed. Ashwood DS0000019273.V361837.R01.S.doc Version 5.2 Page 11 Care plan interventions were aimed at helping the resident maintain their independence. One care plan said, ‘XXXX likes to choose their own clothes each day’. Another one under personal hygiene said, ‘YYYY loves to have a shower --- takes pride in their appearance’. Specific preferences for night needs were included in each care plan. One resident with a diagnosis of dementia had an intervention to manage anxiety about family and finances, which were the two subjects they raised frequently. All the files had risk assessments for moving and handling, tissue viability, nutrition and falls but some had additional assessments for individual needs. In one file there was an assessment for swallowing difficulties and in another for the use of oxygen as the resident had respiratory problems. The records of one resident recorded that they ‘barricaded’ themselves into their bedroom each night. Night staff recorded that they were unable to check on the resident due to the barricade. There was no risk assessment or action plan to help staff manage if an emergency arose for this resident during the night. Records were kept of multi-disciplinary support for residents including visits from the GP, chiropodist, community nurse and psychiatrist. Changes in treatment or medication and diagnostic tests such as blood tests were all recorded. A visiting community nurse was spoken with and said they found the referrals made to their service timely and appropriate. The carers were knowledgeable about the residents and carried out instructions promptly and correctly. Daily records were generally good giving information about how the resident had spent their day and what mood they had been in during the day. However in spite of detailed information collected in the assessments about residents’ preferences for maintaining personal hygiene the records did not always note when a resident had a bath or shower. In two records seen only two baths were noted over a period of three months and the assessment for one resident said they preferred showers but there was no evidence that that preference had been respected. Part of the medication administration round at lunchtime was followed. The carer explained that they had had medication training but were due for an update this year. The home uses a monitored dosage system (MDS) so tablets are supplied in individual blister packs that have been prepared by a local pharmacy. There is a signature sheet for the carer doing the round to sign at the start of each administration to record who was responsible for medication on that shift. The night team leader does a check each night on the previous day’s medication administration records (MAR sheets) to ensure they were completed correctly. The MAR sheets seen during the inspection had no signature gaps and all had an identification photograph of the resident attached. Ashwood DS0000019273.V361837.R01.S.doc Version 5.2 Page 12 The controlled drugs (CDs) stock and register were checked. CDs were correctly stored and a random check showed that the stock tallied with the records. The medication policy was seen and offers comprehensive guidance to staff including procedures for administering ‘homely’ remedies, covert administration of medicines and the application of topical preparations. Care practice was observed during the day and staff were seen to knock on doors and wait to be invited into rooms. Carers spoken with gave clear examples of how they would work to maintain the dignity of residents during personal care. One carer was observed adjusting a resident’s clothing that had become caught up and another knelt down beside a resident to make eye contact while asking a question. Ashwood DS0000019273.V361837.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 good. People who use this service can expect to be offered meaningful pastimes and a well balanced diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three of the five files seen contained a life history of the resident that included family relationships and significant dates such as birthdays and wedding anniversaries. The home has recently appointed an activities co-ordinator and collating life histories is one of the pieces of work they plan to complete over the next months. Carers spoken with said they found the life work very helpful when working with residents, particularly people with a diagnosis of dementia. All the files had contact details of the residents’ next of kin or preferred representative. The assessments of need identified family input with the resident. The home has an open visiting policy and visitors were seen arriving during the day. One visitor spoken with said they were always welcomed by staff and could see people in private if that was the resident’s choice. Ashwood DS0000019273.V361837.R01.S.doc Version 5.2 Page 14 The newly appointed activities co-ordinator has only been in post a few days but has begun to collect information about residents’ likes and dislikes and preferences for outings and activities. There is a weekly activity programme for pastimes within the home that includes games, music and a film afternoon. The co-ordinator said they had taken some residents earlier in the week to the nearby river to feed the ducks. They were planning future events and outings for the summer such as a fete and a visit to the seaside. They intended to consult with the residents about their choices and hoped to be able to have meetings within individual bungalows. All the files had a record of the residents’ religion if they had any beliefs. One visitor spoken with said they had just accompanied a resident to a Salvation Army meeting, which they did twice a week. They said that some representatives of the Salvation Army were going to visit the home regularly to hold meetings for any resident who wished to join them. The file of one resident recorded that they attended a weekly social club in the town. Another said, ‘ZZZZ enjoys the responsibility of making early morning tea for the other residents’. Another record showed that the resident liked to help with day-to-day household tasks around the bungalow. The menus were seen and showed that there is a cooked breakfast offered twice a week and two choices of main dish every day at lunch. The menu for the day is written on a board displayed in each dining area. On the day of inspection the choice was savoury mince or sweet and sour pork followed by semolina or ice cream. One resident said they always have fish and chips on a Friday and a full roast on a Sunday. Meals are served from hot trolleys sent from the main kitchen to each bungalow. Lunch on the day was hot and smelled appetising. Judging from the number of clean plates the residents enjoyed the meal. People spoken with said the food is always tasty. The kitchen was visited and the stores of dry goods and the contents of refrigerators and freezers were inspected. Food was correctly stored and in date. The cook said they have dry goods delivered fortnightly and fresh fruit and vegetables daily. The kitchen had been inspected by the Environmental Health department in March 2008. They had left a very good report and commended the service for attending to all the previous concerns they had raised. The temperatures of the refrigerators and freezers in the kitchen were monitored and records showed they were functioning within safe limits for food storage. The refrigerators in each bungalow kitchen did not have thermometers and were not being monitored although food items were stored in them. Ashwood DS0000019273.V361837.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 good. People who use this service can expect to have concerns taken seriously and be protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a robust complaints policy that was on display in the main entrance hall and can be found in the statement of purpose as well. The complaints log showed that there had been a number of complaints during the last year. Some were around care practice, one was about a malfunctioning radiator, one was about poor laundry care and another about the application of topical preparations. There was evidence in each case of a full investigation with details recorded and a written response and explanation sent to the complainant. The policy relating to recognition and management of abuse was seen and did not refer to the most recent guidance called Safeguarding Adults. The area manager said that Runwood Homes were aware of the changes, that senior staff had already had the new training and a new policy was being produced for all their homes. Staff spoken with had had recognition of abuse training and were clear about their duty of care. One resident spoken with said, ‘I am very happy here. We have freedom to come and go but I feel safe’. Ashwood DS0000019273.V361837.R01.S.doc Version 5.2 Page 16 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, 26. Quality in this outcome area is good. People who use this service can expect to live in a clean, homely environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of all six bungalows was undertaken with the deputy manager at the start of the inspection but most areas were revisited later during the day. There were no unpleasant odours noted on the day. One visitor spoken with said they had never noticed an unpleasant smell when they visited the home. All the bungalows were clean and tidy and residents were using all areas including enjoying the sunshine in the conservatory at the front of the building. Residents’ rooms were personalised with ornaments, pictures and small items of furniture. Each room had clear identification of the resident on the door, some with favourite motifs of flowers or animals included. Ashwood DS0000019273.V361837.R01.S.doc Version 5.2 Page 17 The home has a laundry room that serves all the bungalows and a dedicated laundry worker. The laundry was visited and although busy was clean and tidy. The member of staff explained some of the processes involved in managing the laundry for the whole home. All the washing machines have automated product feed to eliminate staff handling potentially harmful substances. Soiled linen is kept apart from other washing and protective clothing is used when managing it. There was provision of liquid soap and paper towels for hand washing. Ashwood DS0000019273.V361837.R01.S.doc Version 5.2 Page 18 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 adequate. People who use this service can expect to be supported by staff who are trained to do the job but cannot be assured that there will always be enough carers to cover the shifts. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The duty rotas were seen and showed that during the morning there are nine carers on duty, in the afternoon and evening there are six or seven and at night there are four. Each shift has a care team manager to lead it and the deputy manager is supernumerary. The home has some vacancies for carers and is recruiting to the posts however staff spoken with said that morale was low at present due to staff shortages. The deputy manager, who has only been in post a number of weeks, said they were aware of the issues and trying hard to minimise the impact of the vacant posts by using some agency staff and the home’s own bank staff to ensure that numbers were maintained. In addition to the care team the home has an activities co-ordinator, an administrator, a laundry worker, a team of domestic workers and kitchen staff. The home also has a vacancy for a maintenance person and is actively recruiting to fill the post. Ashwood DS0000019273.V361837.R01.S.doc Version 5.2 Page 19 The files for four recently appointed staff were seen and all contained copies of a criminal record bureau (CRB) check. Three files had two references but the fourth only had one reference. Evidence of complete identification checks was missing from two files and one had a very incomplete work history. All files had copies of a contract of terms and conditions of employment and a job description for the appointed post. There was evidence that all the staff had had an induction appropriate for the job they had been appointed to. The training matrix was seen and showed that mandatory training sessions were ongoing throughout the year covering first aid, moving and handling, understanding dementia, health and safety, food hygiene, fire awareness and recognition of abuse. A number of staff have completed their NVQ level 2 course but the percentage of the team does not meet the recommended level of fifty percent in the national minimum standard (NMS) 28. Ashwood DS0000019273.V361837.R01.S.doc Version 5.2 Page 20 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. People who use this service can expect to live in a well managed home and have their welfare protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a registered manager in post who has recently achieved their registered managers award (RMA). The manager is on a leave of absence at the present time and the deputy manager and area manager for Runwood Homes are responsible for the day-to-day running of the home in the interim. The deputy manager demonstrated clear leadership qualities during the day and was approachable and friendly with residents and staff. Ashwood DS0000019273.V361837.R01.S.doc Version 5.2 Page 21 Residents spoken with during the day said they could talk to any member of staff if they had any issues or concerns. The home has an ‘open door’ management policy for residents and staff to air their views and make suggestions. Regular meetings are held and minutes are made available to people who were unable to attend. The minutes for two staff meetings were seen and showed that a wide range of issues were discussed from dress code to cleanliness of the home, mealtimes, medication and recruitment issues. The administrator demonstrated the system used for managing residents’ personal monies. There were some anomalies shown, one resident had two record sheets with different balances showing and the wallet with the change did not contain the correct amount. The difference was found in a second safe put there by staff who did not have access to the main safe. The administrator said they had been on annual leave the previous week and had not caught up with all the transactions that had taken place while they were away. They said they were planning to set up a more robust system for protecting the monies and the staff who handle it. A number of service certificates and the fire log were seen. All lifting equipment and specialised baths were inspected in March 2007 and the electrical installation and emergency lighting were certified as safe in July 2007 with a valid certificate for three years. There was a gas inspection done in February 2008 and the area manager said they were waiting for the certificate but was able to show the work docket. The fire alarms and extinguishers were inspected by external consultants within the last year and records of fire drills showed good staff responses. Ashwood DS0000019273.V361837.R01.S.doc Version 5.2 Page 22 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 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 3 Ashwood DS0000019273.V361837.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 13 (4) (b) Requirement A risk assessment and action plan must be developed to take account of any resident’s unusual behaviour that could potentially put them at risk to ensure that staff can protect residents. All refrigerators must have temperature checks monitored and recorded to ensure that they are functioning within safe limits for food storage. Evidence of all the recruitment checks required in Schedule 2 must be retained for inspection in staff files to evidence that appropriate staff are employed. A robust system for managing residents’ personal monies must be put in place to protect their interests and the staff who implement the system. Timescale for action 03/04/08 2. OP15 13 (4) (c) 03/04/08 3. OP29 19 (1) (b) Sch 2 03/04/08 4. OP35 16 (2) (l) 30/04/08 Ashwood DS0000019273.V361837.R01.S.doc Version 5.2 Page 24 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. Refer to Standard OP7 OP28 Good Practice Recommendations Daily records should include whether a resident has had the opportunity to have a bath or shower following their expressed preference. Steps should be taken to raise the percentage of the care team who achieve an NVQ level 2 to ensure residents are supported by well trained staff. Ashwood DS0000019273.V361837.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Ashwood DS0000019273.V361837.R01.S.doc Version 5.2 Page 26 - 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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