Inspection on 13/08/07 for Ailwyn Hall Care Home

This inspection was carried out on 13th August 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ailwyn Hall Care Home 13/12/06

Ailwyn Hall Care Home 31/08/06

Ailwyn Hall Care Home 23/08/05

Ailwyn Hall Care Home 05/04/05

Ailwyn Hall Care Home 21/09/04

Ailwyn Hall Care Home 22/04/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Ailwyn Hall Care Home Berry`s Lane Honingham Norwich Norfolk NR9 5AY Lead Inspector Ann Catterick Unannounced Inspection 13th August 2007 09:15 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 Ailwyn Hall Care Home DS0000055861.V348606.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. Ailwyn Hall Care Home DS0000055861.V348606.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ailwyn Hall Care Home Address Berry`s Lane Honingham Norwich Norfolk NR9 5AY 01603 880624 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) info@ashleycaregroup.com Gastank Ltd Ms Samantha Beck Care Home 39 Category(ies) of Dementia (39), Old age, not falling within any registration, with number other category (39) of places Ailwyn Hall Care Home DS0000055861.V348606.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th December 2006 Brief Description of the Service: Ailwyn Hall is a care home providing personal care and accommodation for 39 older people, most of whom have dementia. The home comprises of two units Emily unit and Rosie unit. The home is owned by Gastank Ltd and the responsible individual is Ashley Oliver George. The home is located in the village of Honingham. The home is close to the main A47 providing easy access to both Norwich and Dereham. The home has 30 single rooms, 19 of which are en suite and 4 double rooms, 2 of which are en suite. The home has a passenger lift. The home is set in a picturesque setting in its own grounds surrounded by mature trees and well maintained gardens. There is parking to the front and to the side of the property. The weekly fee at the time of writing the report is between £347 and £525 a week. Ailwyn Hall Care Home DS0000055861.V348606.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection that was unannounced and took place on 13th August 2007. The site visit was over a period of 8 hours. The report includes information received by the Commission since the last inspection including an Annual Quality Assurance Assessment and 4 comment cards from relatives and 4 comment cards from residents. The home now has more residents with dementia than previously and most residents admitted to the home in the future will now have varying degrees of dementia. The proprietor has plans to extend the building to provide additional places although these have not yet been finalised. Information was sent to the Commission by the Manager identifying what the home had done well, what improvements could be made and what plans for change there were for the next twelve months. Comment cards received were positive and no concerns have been received about the home since the last inspection. Ailwyn Hall is an improving home and since the new manager has been in post there have been considerable improvements to all aspects of the care provided. The overall outcomes for people living in the home are good. Comments made by residents ‘Happy with my care, stay in my room most of the time.’ ‘Girls are extremely good.’ ‘I have a morning paper and breakfast in my bedroom.’ ‘Have peace of mind.’ ‘Food excellent.’ ‘Staff excellent.’ Comments by relatives ‘Lots of improvement since new manager in post.’ ‘The family are very satisfied.’ ‘Have had no relative meetings for a while.’ ‘Very lucky to be here.’ Ailwyn Hall Care Home DS0000055861.V348606.R01.S.doc Version 5.2 Page 6 Comments by staff ‘Lots of improvements.’ ‘Staff and residents happier.’ ‘Well managed.’ ‘Big improvement with staffing.’ ‘Would always report poor practice.’ ‘We have new uniforms.’ ‘Good training.’ What the service does well: What has improved since the last inspection? There have been improvements in the general ambience of the home. A new bathroom and shower room have been installed. Staff are encouraged to work with residents in a person centred way. All areas of the home were clean and free from any offensive odour. If a resident is in hospital their room is now always locked to maintain privacy and security. Window restrictors have now been fitted to all upstairs rooms. The boiler room is now always kept locked. Ailwyn Hall Care Home DS0000055861.V348606.R01.S.doc Version 5.2 Page 7 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. Ailwyn Hall Care Home DS0000055861.V348606.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 Ailwyn Hall Care Home DS0000055861.V348606.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): 1, 2, 3 and 6 People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prior to admission prospective residents can expect to be provided with information about the home and to have their needs assessed to ensure the home is an appropriate placement for them. Once a placement is agreed they will receive a contract identifying the terms and conditions of the placement. EVIDENCE: A copy of the Statement of Purpose and Service User Guide were seen and prospective residents and their families are given copies of these. Residents contracts were seen but did not included the number of the room that the prospective resident would occupy. A recommendation has been made in this area. Ailwyn Hall Care Home DS0000055861.V348606.R01.S.doc Version 5.2 Page 10 When an enquiry is made about a possible admission to the home an enquiry form is completed. Prior to admission the manager would visit a prospective residents and complete a pre admission assessment. Evidence of these forms was seen on the day of the site visit. Those residents seen and spoken to on the day of the site visit were having their needs met. The home does not provide intermediate care. Ailwyn Hall Care Home DS0000055861.V348606.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): 7, 8, 9 10 and 11 People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can be assured that they and their family will be involved in the creation of a plan of care that is centred around their individual health and personal care needs and life preferences. Staff will treat residents in a way that promotes respect, privacy and independence. EVIDENCE: All residents have a plan of care that identifies how their needs and preferences for care will be met. All care plans seen were person centred and provided useful and relevant information in an easy to read format. Ailwyn Hall Care Home DS0000055861.V348606.R01.S.doc Version 5.2 Page 12 At the front of the care plan there is a photograph of the resident with a snap shot assessment. This gives, on one page, all of that information needed to give a carer a clear understanding of the residents needs. This includes comments on memory, behaviour, communication nutrition mobility, skin care, physical health and social needs. This is followed by life story information that is requested from relatives, friends and the resident to enable staff to have meaningful communication with residents. It also enables staff to have an understanding of the whole person and not just their presenting needs. It includes information about childhood, family, adult life, previous occupation, previous hobbies and interests, community and social activities and reasons for admission. The needs of the individual resident are then identified and are incorporated within the care plan. For example for a resident who had fragile skin the care plan identified this as a problem and them identified what needed to happen to promote healthy skin. ‘Ensure skin well moisturised, high protein diet, high fluid intake, care dressing and undressing, document all bruising and refer any skin tears to the district nurse.’ Another example was with regard a resident who was diabetic.’ ‘Administer medication, offer balanced diabetic diet, encourage regular fluids, monitor blood sugar levels, refer to chiropodist, ensure annual optician appointments, check peripheral areas for injury’. Where a resident may display aggressive behaviour the care plan identified trigger points to the behaviour and identified how to minimise these. These examples are evidence of good practice and should be commended. Health needs were clearly identified in the care plans and the relationship between the community health service and the home is good. A resident who was being cared for in bed had a pressure care chart upon which some staff recorded fluid intake but there was no individual fluid chart. A recommendation has been made in this area. Medicines are stored safely and the NOMAD system is used. All of those staff who care for and administer medication have been trained to do so. On the day of inspection the administration of medication was observed and seen to evidence good practice. An audit of some of the separate boxed medication took place and was found to be in good order. No residents are self medicating but if this were the case an appropriate risk assessment would take place. Throughout the day of the site visit the interaction between residents and staff was good and staff interacted with residents in a way that promoted dignity and respected privacy. Ailwyn Hall Care Home DS0000055861.V348606.R01.S.doc Version 5.2 Page 13 If a resident is coming towards the end of their life the home will, whenever possible, enable the resident to remain in the home. This is done with consultation and support from the local GP practice. Ailwyn Hall Care Home DS0000055861.V348606.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, 13, 14 and 15 People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can expect staff to take an interest in what hobbies or preferences they have and for these leisure pursuits to be included in the activities and occupation offered to the individual. Residents can expect their visitors to be made welcome. Residents can expect to be provided with nourishing home-made food that is provided by a cook who regularly canvasses residents to get their views and feedback about the food provided. Ailwyn Hall Care Home DS0000055861.V348606.R01.S.doc Version 5.2 Page 15 EVIDENCE: The home has an activity worker who is employed 09.00 16.00 Monday to Friday. She has received training with regard introduction to reminiscence and is completing her NVQ level 3 with specific emphasis on activity and interaction with older people with dementia. She is hoping to complete arts and crafts training in September. A programme of events shows different activities as well as specific times when the activity person works one to one with residents. It is also recorded who attends any activity to ensure all resident have the opportunity for joint activity or one to one sessions. Service users hobbies and interests are identified in their care plan. A foot care lady visits on a regular basis offering foot care and a massage advising when chiropody may be needed. She also had a very friendly greyhound who is appreciated as a lap dog. The home has purchased fish and guinea pigs as an additional interest for residents. In the day of inspection two new residents were spending time with the activity person who was enquiring as to what their preferences were for their leisure time. In the afternoon one resident was using watercolour pencils, one was crayoning and another was sketching with pencils. Residents were able to use different media depending on preference and ability. The home has recently had a summer fete. The mobile library visits every three weeks. Visitors are made welcome in the home and several visitors were spoken to on the day of inspection. A local church offers a regular service in the home for anyone wishing to attend. Most residents have their finances cared for by relatives or financial advocates. If a resident chose to take responsibility for their own finances a risk assessment would be completed and appropriated safety measures taken. Several residents have some money on their person and more significant amounts are looked after by the home. Since the last inspection the home has appointed a new cook. Menus have changed and the new cook prefers all meals to be homemade whenever possible. She makes homemade cakes every day. Ailwyn Hall Care Home DS0000055861.V348606.R01.S.doc Version 5.2 Page 16 Residents choose what they want to eat as they sit down for dinner. This is seen as good practice. There are always two main choices and a resident did not like these they could choose something else. There are always two choices for tea and one of these is a cooked dish. Home made scotch eggs were being prepared for tea on the day of inspection. The cook talks to residents and gets feedback and suggestion about the food provided. The dining areas in both units are bright and welcoming. Since the last inspection there is more dining seating accommodation on Emily unit and all residents could sit at dining tables if they chose to do so. If a resident does not want to eat at lunch time or only eats a little, snack boxes are provided for residents to have with them and the are then able to snack when they wish. This was seen as good practice. In Rosie unit there is a blackboard menu to inform residents on choices for meal times. All staff have received MUST training and the cook is aware of the particular dietary needs of residents. Staff were available to assist those residents who needed it with their lunch and this was done in a caring respectful way. Ailwyn Hall Care Home DS0000055861.V348606.R01.S.doc Version 5.2 Page 17 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 and 18 People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents living in the home are given the information needed to enable them to share any concerns or complaints that they may have. Staff receive safeguarding adults training. This means that the staff who look after residents are trained to do so in an appropriate way and have been encouraged to report any poor practice seen. EVIDENCE: A copy of the homes complaints procedures is at the front of the house and included in the home’s Statement of Purpose. There have been no formal complaints since the last inspection. Staff have received Safeguarding Adults training and the home has a policy and procedure in this area. All of the staff spoken to said that they would report poor practice and the atmosphere in the home is open and transparent. Ailwyn Hall Care Home DS0000055861.V348606.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, 20, 21, 25 and 26 People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can expect to be provided with suitable accommodation that meets their needs. They can expect for the environment to continue to change and improve as the plans to extend the home in the coming year materialise. Ailwyn Hall Care Home DS0000055861.V348606.R01.S.doc Version 5.2 Page 19 EVIDENCE: Since the last inspection there have been significant improvements to the environment. The home has large grounds and some areas are now safe areas for residents. Two residents were seen sitting in the grounds on the day of the site visit. The shingle driveway at the front of the home continues to offer poor access for residents and visitors with mobility difficulties. There is still a ramp blocking the pathway running around the home that prevents continuous access for those in wheelchairs. The manager explained that as there are plans to extend the property it would not be cost effective to alter this when it may soon be destroyed with the new building work. Communal areas have been improved and some refurbishment has taken place. As there are plans to extend the home next year no major refurbishment is taken place in the home. The carpet in the Rosie lounge is however badly stained and cannot remain like this indefinitely. A requirement has been made in this area. Lots of prints have been bought and the environment is generally more welcoming and homely. Within the entrance hall a small seating area has been created and includes a fish tank as a point of interest for residents. Names are now on bedroom doors and more signage is being used in the home. There is still opportunity for further development in this area. A downstairs area that was previously an unused bathroom has now been made into a shower room and a large bathroom has been created on the first floor by making two rooms into one and purchasing a new bath. The home now has enough bathing facilities to need the needs of residents. Bedrooms have new duvets covers and curtains and some bedrooms have new carpets. The upstairs bedroom corridor in Rose unit is still dull and brighter light bulbs have made little difference. The manager said that additional light fittings may be the answer and is looking into this. The laundry and kitchen would both benefit from being bigger and this will be the case when the new extension is completed. There continues to be no handrail on Emily unit and the manager is in the process addressing this concern. A requirement has been made in this area. Ailwyn Hall Care Home DS0000055861.V348606.R01.S.doc Version 5.2 Page 20 Assisted technology is used when appropriate. Residents are assessed to see whether a call bell will meet their need and if so one is fitted. On the day of the site visit the home was clean and tidy and free from any offensive odours. Ailwyn Hall Care Home DS0000055861.V348606.R01.S.doc Version 5.2 Page 21 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 and 30 People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can expect there to be enough trained and competent staff on duty to meet their needs. EVIDENCE: The staff rota was inspected and initially the number of care staff on duty did not appear to be sufficient - five care staff on duty during the mornings and five care staff in duty during the afternoons and evening. However on further inspection it was noted that Monday to Friday the manager and deputy manager are on duty with the deputy manager taking an active role in the home and with the manager being very visible, for example helping to serve lunch on the day of inspection. A full time activities person is in the home five days a week and domestic and housekeeping staff make the beds and tidy bedrooms. A kitchen assistant serves drinks during the morning and afternoon as well as preparing tables for meals. This means that care staff have much more time to spend with residents even though they complete all laundry tasks. Outcomes for residents were good on the day of inspection and staff were working in a relaxed and unhurried way. Ailwyn Hall Care Home DS0000055861.V348606.R01.S.doc Version 5.2 Page 22 Those staff who do not have English as a first language have completed the appropriate English language courses and one member of staff won an award for their progress. Over 50 of staff have NVQ level 2 or above and seven staff are in the process of completing their level 2 NVQ. The manager is an NVQ trainer and assessor and is hoping to have almost 100 staff trained by the end of the year. The home is just outside the village of Honingham and not on a bus route, which means recruiting staff is a continuing challenge. Staff files were inspected and the appropriate documentation was seen on file. One staff member had moved from a kitchen role to a caring role and had not had an enhanced CRB completed. This was an oversight of the manager and she agreed to follow this up immediately. Staff training has improved and all staff said that there was continuous training taking place within the home. Evidence of training completed was seen in staff files. The home is now admitting more people with dementia and staff are having more training in this area. Examples of training that has taken place are, introduction to dementia, communication and dementia and other specific training. New staff receive induction training that follows the recommendations of the common induction standards. The documents used are kept on computer and staff do not have their own workbooks. All new staff need to be given induction workbooks to complete whilst completing their practice. A requirement has been made in this area. Ailwyn Hall Care Home DS0000055861.V348606.R01.S.doc Version 5.2 Page 23 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, 36 and 38 People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can expect the home to be managed by a person who has the qualifications, experience and knowledge to fulfil her role in full promoting good practice and providing good outcomes for residents. EVIDENCE: The manager has the appropriate qualifications, skills and knowledge to fulfil her role, including a Diploma in dementia care. She has recently been appointed as the Registered Manager for the home. Staff spoken to were positive about the manager saying she was supportive and offered much opportunity for staff development and training. Staff felt that there had been significant improvements in the home over recent months. Ailwyn Hall Care Home DS0000055861.V348606.R01.S.doc Version 5.2 Page 24 The home has regular staff meeting and supervision and is to try and encourage more resident and relatives meetings. A recommendation has been made in this area. Questionnaires have been sent to residents, relatives and staff and this information is shared in the Ailwyn Hall Care Home news. The manager feels this is an area for further development and is to complete a comprehensive audit of the service later in the year. The cover for the radiator in the new bathroom is awaiting the installation of the bath chair as then the appropriate radiator cover can be fitted. The radiator in the hairdressing room needs to be made of low temperature or to be covered. All upstairs windows now have window restrictors fitted. The manager audits the incidents and accidents in the home to look a general numbers and to see if any patterns occur. This was seen as good practice. Ailwyn Hall Care Home DS0000055861.V348606.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 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 2 3 x x x 3 3 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 3 3 2 x 3 3 x 3 Ailwyn Hall Care Home DS0000055861.V348606.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 OP19 Regulation 23.2 (d) Requirement The registered person must ensure that the carpet in Rosie unit is cleaned to remove all staining or replaced. This would ensure a clean and wellmaintained carpet for residents to enjoy in this communal area. The registered person must ensure that the physical environment meet the needs of service users. This relates particularly to the environment on Emily unit and the lack of a handrail in the corridor. This will assist residents to move about the home safely. This is a repeat requirement. The registered person must ensure that new staff have the relevant documentation and paperwork to fulfil the requirements of the common induction standards. Timescale for action 01/11/07 2. OP22 23.2 01/11/07 3. OP30 18.1 © 01/11/07 Ailwyn Hall Care Home DS0000055861.V348606.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3 Refer to Standard OP2 OP8 OP33 Good Practice Recommendations It would be good practice to ensure that the number of the room that a resident was to occupy was identified in the statement and terms and conditions of the placement. It would be good practice that a separate fluid chart is used when a resident is to be cared for in bed. It would be good practice for the manager to encourage more resident/relative meetings. Ailwyn Hall Care Home DS0000055861.V348606.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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