Inspection on 28/08/08 for Ashgreen House

This is the latest available inspection report for this service, carried out on 28th August 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 16/12/2008.

CARE HOMES FOR OLDER PEOPLE Ash Green House Sandbach Place Woolwich London SE18 7EX Lead Inspector Keith Izzard Key Unannounced Inspection 03.15p 28 August & 3 & 9 September 2008 th rd th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ash Green House DS0000067480.V367281.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. Ash Green House DS0000067480.V367281.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ash Green House Address Sandbach Place Woolwich London SE18 7EX 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 8331 7249 020 8331 7259 judith.clark@sanctuary-care.com www.sanctuary-care.co.uk Sanctuary Care Ltd Vacant Post Care Home 52 Category(ies) of Old age, not falling within any other category registration, with number (52) of places Ash Green House DS0000067480.V367281.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 - Code 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: 52 19th July 2006 Date of last inspection Brief Description of the Service: Ash Green House is a registered care home offering 33 conventional residential care placements on Abbey, Ferry and Trinity units, 9 nursing placements on Winns unit and 10 Intermediate Care placements on Artillery unit. The home is a modern building that opened in 2004 and is situated mid way between Woolwich and Plumstead, South London. The home is one of three Neighbourhood Resource Centres initially operated by Ashley Homes and now by Sanctuary Care that replaced four homes previously operated by the London Borough of Greenwich for older persons. A day centre is also located on site and both this and the intermediate care units have dedicated areas and facilities within the building as required in the National Minimum Standards. The Intermediate care unit, provides a specialist rehabilitative service prior to final discharge back into the community of 10 service users who, have either been admitted from the community or direct from hospital. The home is well provided for in terms of communal facilities for service users including dining areas, hairdressing facilities and numerous quiet areas and transport for outings. Resident and relatives meetings are held on a regular basis on each of the units. The fees charged by the home at the time of inspection range from £695£750.00 per week. This does not include additional charges such as chiropody, hairdressing, newspapers and outings Ash Green House DS0000067480.V367281.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 2 Star. This means the people who use this service experience good quality outcomes. This inspection was unannounced and was carried out over three separate days on 28/08/08, 3/09/08 and 9/09/08. The first day of inspection was very brief, only one and a half hours. We visited all five units within the home over the three days. In preparation for the inspection we read all of the information that we had received about the service since the last inspection such as concerns and complaints, comment cards, notifications and the Annual Quality Assurance Assessment (AQAA) form. The latter was comprehensively completed and submitted in good time by the Registered manager. We used this information to plan how we would carry out the inspection and what issues we would look at. During the inspection we spoke with six residents, two relatives, and eight members of staff as well as the manager and deputy. We observed staff communicating with residents and visitors, supporting residents to eat and drink and take their medicines, in a professional and caring manner. All of the communal areas and several bedrooms were viewed on each of the five units that we visited. What the service does well: People were supplied with written information about the service and were actively encouraged to visit the home to view the facilities and ask questions. There is a good display of information about the home in the reception area, and accessible for visitors to see. Senior staff members assess potential residents considering a move into the home to see what help they required and if they had any special needs, this also included short- term carer breaks. This information was used to develop a Ash Green House DS0000067480.V367281.R01.S.doc Version 5.2 Page 6 plan of care for the person and establish a rapport with residents and relatives prior to admission. There was a relaxed calm atmosphere on all the units visited. Residents had access to community health care services. Health problems were monitored and advice was obtained from other professionals if necessary. Residents were appropriately dressed and looked relaxed. They told us that staff maintained their privacy and were polite and helpful. People could choose where and how they spent their time and staff encouraged people to make decisions for themselves where possible. This new home provides a very bright and airy environment throughout and individual en suite accommodation of a good standard for residents. Overall, the home was clean, tidy and safe for residents who were cared for by staff members who were both caring and professional in their relationship with residents. Health and Safety requirements had been attended to satisfactorily. The responses from six residents interviewed and from ten who completed questionnaires were generally favourable and positive comments were made about the caring attitude of care staff by many of them. What has improved since the last inspection? What they could do better: All residents including those admitted for respite care must have letters sent to them prior to their admission confirming the home can meet their needs. Ash Green House DS0000067480.V367281.R01.S.doc Version 5.2 Page 7 The proposed plan to appoint a dedicated activities person should take place as soon as possible in order to improve the quality of activities for residents. The acting manager has now been managing the home for over 12 months and should apply for registration, in the absence of another candidate being put forward for the application of Registered Manager. All night- time care staff members should be included in fire drills at least two times per annum. Dated stickers should be attached by visiting service engineers, to all moving and handling equipment, including specialist baths, to facilitate easy reference that equipment has been examined within the required six-monthly time frame. 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. Ash Green House DS0000067480.V367281.R01.S.doc Version 5.2 Page 8 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 Ash Green House DS0000067480.V367281.R01.S.doc Version 5.2 Page 9 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Comprehensive information is provided to relatives and residents in order to assist them to make an informed decision in their choice of home. Senior care staff carried out a care needs assessment before confirming if the home could meet people’s needs, but respite care residents must receive the same service. Service users provided with intermediate care are helped to maximise their independence and return home. EVIDENCE: Standard 1 At the previous Key inspection requirements were made to update both the Statement of Purpose and the Service User Guide. Both documents had been Ash Green House DS0000067480.V367281.R01.S.doc Version 5.2 Page 10 appropriately updated and copies of the Service User Guide made available to al residents this also included a specific document for all residents admitted to the Intermediate Care Unit. Standard 3 Residents’ care plans were examined on each of the units and in respect of long term residents all those seen had copies of letters confirming the home could meet the needs of residents that had been sent prior to their admission to the home. In respect of one respite care resident file seen this had been omitted and a requirement is therefore made that respite care residents must also receive these in future. See Requirement 1 Standard 6 The intermediate care unit was clean, tidy and spacious. The unit includes excellent facilities for rehabilitation such as an adapted kitchen, physiotherapy room and specialist equipment to promote residents independence. The aim of the unit is to provide a period of rehabilitation for residents following illness or surgery, which enables them to return to their own home. The unit holds regular multidisciplinary meetings to assess resident’s progress and review care plans. Feedback was obtained from two residents who were staying on the unit. Both residents said they were highly satisfied with the care and assistance they had received. A specific Service User Guide for the unit had been developed and supplied to each service user. Ash Green House DS0000067480.V367281.R01.S.doc Version 5.2 Page 11 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans showed the action that staff were taking to monitor and care for people with ongoing health care needs. Residents and relatives said staff treated them with respect and maintained their privacy and dignity. Medications were generally well managed. EVIDENCE: Standard 7 Two sets of records were assessed on each unit. On all units the care records viewed were satisfactory and reflected residents’ social needs and personal preferences. On the nursing unit one resident’s care plan/risk assessment gave clear instructions regarding moving and handling; specifying two care staff members to use a sliding sheet and for transfer two staff to use a tempo hoist. Monthly scores were maintained in respect of a pressure sore including body Ash Green House DS0000067480.V367281.R01.S.doc Version 5.2 Page 12 map and an ongoing photographic record. Nutrition and weight records were made monthly and turning records evidenced that the resident had been turned and repositioned four hourly, as required in the care plan. Care plans seen were agreed and signed by the resident or relative and were reviewed regularly. On the intermediate care unit care plans on this outlined what individual residents wanted to achieve and specific timescales for achieving personal goals. Staff generally had assessed residents’ risk of developing pressure sores, risk of falls and nutritional needs and had developed strategies to reduce risks. Standard 8 Access to community health care services was good. The records seen indicated that some residents had appropriately been assessed or reviewed by the GP, Optician, Tissue Viability Nurse and Care Managers and reviews undertaken for the provision of bedrails. Risk assessments Standard 9 Medicines were assessed on two of the units. Six MAR sheets were examined in total. Records of receipt of medicines were good. Medication was stored in a locked cabinet within the lockable clinical room and quantities and dosage of medication tallied with the MAR sheets examined and the amount remaining within the storage system. The home had a policy and procedure for medication that was comprehensive and only staff members who had received training were allowed to deal with medication. The manager stated that advice was readily available from the supplying Pharmacist and had a homely remedies procedure in place signed by the GP for the home. The medication room and medication refrigerator temperature was monitored and Medication audits were taking place regularly. We observed a senior member of the nursing staff dealing with medication at lunchtime from the medication trolley and noted that good procedures were adopted and that medication was only signed for, after it was observed by the staff member to have been taken. Standard 10 Seven residents interviewed and a further ten who completed CSCI questionnaires said that staff members treated them with respect and maintained their dignity at all times. All staff members observed during the course of the inspection interacted with residents in a professional and caring manner. All residents seen were appropriately dressed for the warm weather and appeared well groomed and cared for. Ash Green House DS0000067480.V367281.R01.S.doc Version 5.2 Page 13 Ash Green House DS0000067480.V367281.R01.S.doc Version 5.2 Page 14 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): 12-15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The provision of activities would be enhanced by the provision of a specialist appointment in this area. Relatives are actively encouraged by staff members to visit the home at any reasonable time. The menu was varied and people said they liked the food that was prepared in the home. EVIDENCE: Standard 12 Care records seen showed that staff members record residents’ likes and dislikes at the time of admission along with historical details of their past life. This provides staff with a picture of what activities and interests might best be provided and encouraged by staff. An activities programme was displayed on Ash Green House DS0000067480.V367281.R01.S.doc Version 5.2 Page 15 each of the units that showed a wide range was being provided including board games, nail care, sing a long Bingo Reminiscence chair exercise newspaper and discussion and outings. The home does not currently have a dedicated activity coordinator but this is being planned for the future and this should enhance the current provision. A number of residents and staff felt that more activities could be provided and it is therefore recommended that this appointment be made as soon as possible. See Recommendation 1 Standard 13 The home has an open visiting policy to make it possible for residents to maintain contact with family and friends. Residents seen said they enjoyed family visits and relatives were encouraged to attend social functions and relative meetings. Relatives we spoke to stated they were made feel welcome when visiting and found care staff approachable, helpful and informative. There are no restrictions in relation to visiting times and friends and relatives are actively encouraged to visit at any reasonable time. Standard 14 All the residents we spoke to said they could make their own choice about meals, what to wear, where to sit and whether to participate in activities or not. Residents were able to bring in personal items from home to make their bedrooms more personal and evidence of this was seen on all units within the home. Standard 15 Residents who we spoke to during and after lunch stated that a choice of meals was offered and if they did not like the main choice an alternative would be provided. Residents stated food provided was of a good standard. Fresh water dispensers are provided on each unit and staff members were seen to provide service users with refreshments throughout the day. Meals were observed in two of the dining areas on the residential care units and it was noted that tables had been set appropriately and that staff members discreetly assisted those residents who needed assistance or encouragement to eat. Ash Green House DS0000067480.V367281.R01.S.doc Version 5.2 Page 16 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. Satisfactory systems were in place to manage complaints and ensure residents’ protection. EVIDENCE: Standard 16 The complaints procedure was displayed in the main reception area. All residents and relatives interviewed knew how to make a complaint. The AQAA showed that in the previous twelve-month period, two minor complaints had been made to management and following investigation one of these was substantiated and one not substantiated. All complaints had been dealt with in accordance with the required time frame. No complaints had been referred to the Commission about the home. Standard 18 A policy and procedure was in place in relation to Safeguarding Adults. Staff spoken with had a good understanding of their role in safeguarding adults and understood the ‘whistle blowing’ policy. Staff members interviewed appeared confident that any concerns reported to management would be responded to promptly and that managers were approachable, thereby facilitating the Ash Green House DS0000067480.V367281.R01.S.doc Version 5.2 Page 17 sharing of any concerns. The manager notified The Commission for Social Care Inspection (CSCI) about significant events that occurred in the home such as serious accidents, and deaths and would also report safeguarding issues directly to the local social services authority, should any occur, but none had occurred. Ash Green House DS0000067480.V367281.R01.S.doc Version 5.2 Page 18 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 excellent. This judgement has been made using available evidence including a visit to this service. Residents and relatives were satisfied with the private and communal space provided. The home was kept clean and a rolling programme of maintenance and redecoration work maintained. Systems and equipment was in place to enable staff to practice infection control. The home was clean, comfortable and welcoming. EVIDENCE: Standard 19 Ash Green House DS0000067480.V367281.R01.S.doc Version 5.2 Page 19 A good standard of accommodation is provided for service users who benefit from large single bedrooms with en suite facilities. Bedroom doors are provided with appropriate locks and each service user has a lockable facility in their bedroom. The furnishings and décor are also of good standard. There are secure grounds around the home with appropriate outdoor seating provided. There is an appropriately furnished room for service users wishing to meet with relatives in private and a portable payphone is also provided to ensure service users are able to make and receive telephone calls in private. The home has a designated smoking room. Residents confirmed they had been given the opportunity to bring in personal possessions to personalise their bedrooms and this was noted in a large number of the rooms we saw. Standard 26 All areas of the home seen were clean and free from unpleasant odour. All foul waste was appropriately dealt with. One domestic staff members interviewed demonstrated her awareness of the procedures to be followed to minimise any risk of infection being spread within the home. Laundry facilities are modern and well equipped and the staff member responsible reported no problems with any of the equipment provided. Ash Green House DS0000067480.V367281.R01.S.doc Version 5.2 Page 20 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): 27-30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs are being met by the numbers and skill mix of staff, and they are in safe hands at all times. Residents are protected by the home’s recruitment policy and practices, and staff members are trained and competent to do their jobs. EVIDENCE: Standard 27 Staffing levels are unchanged since the last inspection. Rotas examined and staffing records indicated that there are sufficient numbers of suitably skilled staff employed at the home throughout the day and night at the home. It was noted that longer day- time shifts had been introduced and that staff who we interviewed preferred the new system offering greater continuity of care for residents and more days off. Standard 28 Ash Green House DS0000067480.V367281.R01.S.doc Version 5.2 Page 21 94 of the care staff that worked in the home had a National Vocational Qualification in Care (NVQ Level 2). The number of care staff with a recognised care qualification had increased and this is commendable. A large number of people that we interviewed or received written comments from within CSCI questionnaires, said the home had some very good staff, for example “most staff are kind and helpful” “the staff respect privacy and are patient”. Standard 29 Three personal staff member files were examined, in relation to recruitment and training. Records seen indicate that there are sound recruitment procedures in place to protect residents living in the home. Standard 30 A yearly planned training programme/ matrix was provided and accessible to staff. The programme included routine training such as moving and handling, fire safety adult protection, COSHH, medication supervisory skills and end of life care. Evidence was also available of training being planned for the future. Training records seen showed that staff members had received the training outlined above. Staff members that were interviewed said they received an adequate level of training to enable them to fulfil their roles and that they were encouraged to identify areas of training for themselves in addition to that provided for them by the organisation. Ash Green House DS0000067480.V367281.R01.S.doc Version 5.2 Page 22 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. The acting manager has provided good continuity of care for residents and staff following the resignation of the Registered Manager, but a new appointment of Registered Manager should occur as soon as possible. There were systems in place to monitor and improve the quality of care provided in the home and to safeguard people’s money. Health and safety issues were well managed. EVIDENCE: Ash Green House DS0000067480.V367281.R01.S.doc Version 5.2 Page 23 Standard 31 It was evident that both the residents and staff members interviewed felt positively about the acting manager and all stated that she had maintained improvements in the way the home was run and that she was very approachable, neither residents or staff members would hesitate to speak to her, should they have any concerns regarding the running of the home or the welfare of residents. The commission were notified about the previous registered manager’s resignation but no permanent replacement has been found over the past twelve months. As the acting manager has now been managing the home for over 12 months she should apply for registration, in the absence of another candidate being put forward for the application of Registered Manager. See Recommendation 2 Standard 33 The home has systems in place for monitoring the quality of care and services provided in the home and for obtaining feedback from residents and relatives. Regular audits were carried out to ensure that staff members were following procedures and to identify concerns. In recent months the acting manager and deputy had completed medication and care record audits. The home is subject to an annual audit by Sanctuary Care and is Visited regularly on a monthly basis and a report complied on the conduct and running of the home, as required, under Regulation 26. These reports have been made available to the CSCI and copies are retained within the home. The home is also monitored on a regular basis by the contracting unit from the London Borough of Greenwich and the subsequent reports of these visits are made available to CSCI. The home has a good record of compliance in respect of both CSCI reports and those from the London Borough Of Greenwich. Standard 35 The system for dealing with residents’ personal finance was examined and a good audit trail was seen and no errors found in respect of the three examples that were individually examined. Receipts are obtained for service user expenditure and an ongoing ledger records all money credited and debited in respect of individual service users. Individual plastic zip wallets contain the outstanding balance of cash and receipts obtained for any purchases made and the envelopes retained in a locked safe. The system examined was accountable with a good audit trail. There were clear procedures for staff to follow and money records were checked during monitoring visits and audits. Ash Green House DS0000067480.V367281.R01.S.doc Version 5.2 Page 24 Standard 38 Fire safety arrangements were good. Regular checks were undertaken to ensure that the fire alarm system, emergency lighting, fire extinguishers and fire doors were in working order and equipment was serviced regularly. There were regular fire drills but drills usually took place during the day and did not indicate whether staff members who specifically worked on night duty shifts were included. All night- time care staff members should be included in fire drills at least two times per annum. See Recommendation 3 The home had a dedicated maintenance person. The maintenance person carried out regular health and safety checks and routine repairs within the home and grounds. Health and safety records were sampled. All of the records seen were up to date and corresponded with the information that was provided by the acting manager in the Annual Quality Assurance Assessment (AQAA) report. Hot water temperatures were tested regularly. It was recommended to the manager that dated stickers be attached by visiting service engineers, to all moving and handling equipment, including specialist baths, to facilitate easy reference that equipment had been examined within the required six-monthly time frame. See Recommendation 4 Ash Green House DS0000067480.V367281.R01.S.doc Version 5.2 Page 25 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 2 X X 3 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Ash Green House DS0000067480.V367281.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 d Requirement All residents including those admitted for respite care must have letters sent to them confirming the home can meet their needs. Timescale for action 01/12/08 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. 2. Refer to Standard OP12 OP31 Good Practice Recommendations The proposed plan to appoint a dedicated activities person should take place as soon as possible The acting manager has now been managing the home for over 12 months and should apply for registration, in the absence of another candidate being put forward for the application of Registered Manager. All night- time care staff members should be included in fire drills at least two times per annum. Dated stickers should be attached by visiting service engineers, to all moving and handling equipment, including specialist baths, to facilitate easy reference that equipment has been examined within the required sixDS0000067480.V367281.R01.S.doc Version 5.2 Page 27 3. 4. OP38 OP38 Ash Green House monthly time frame. 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