Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 13/12/06 for Ailwyn Hall Care Home

Also see our care home review for Ailwyn Hall Care Home for more information

This inspection was carried out on 13th December 2006.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

There have been significant improvements since the last inspection. Those visitors spoken to were positive about the care provided in the home. "Nothing wrong with the place at all." "Lots of changes in the last six months." "Good that the old carpets have gone." Generally bedroom accommodation is of a good size. Comment from a service user. "Good bedroom, waiting to have personal telephone installed, very satisfied"

What has improved since the last inspection?

The proprietor has appointed an experienced manager who is improving the quality of care provided within the home. The home has its own improvement plan that is based on previous requirements and is focussed on improving services. The care plan format has improved and is now easier to understand and has much more information. The staff have received further training and are being managed and supported. This is having a positive impact on the quality of care provided to service users. "There is a good staff team and they give 110%." Comment from a staff member. Staff were seen to care for service users in a way that promoted dignity. "Very nice girls." "Treated with respect, very helpful." Comment from service user. "Care good, very good." Comment from a service user. The manager has encouraged more activities in the home and service users clearly have the opportunity to become involved in social activities or have individual time with staff if they chose to do so. There have been less slips, trips and falls than at the previous inspection. Manual handling assessments were seen in care plans. There has been some improvement to the environment.

What the care home could do better:

The home has only two baths that are used by service users and this is not really sufficient for 39 service users. The grounds are not easily accessible to service users. Window restrictors need to be put on some of the upstairs windows. Permanent signage needs to be provided in the home, especially in Emily unit. Not all areas of the home were free from any offensive odours.The laundry equipment is not sufficient as there is only one washing machine and if this breaks down, as on the day of inspection, dirty laundry soon mounts up and can become a health and safety hazard.

CARE HOMES FOR OLDER PEOPLE Ailwyn Hall Care Home Berry`s Lane Honingham Norwich Norfolk NR9 5AY Lead Inspector Ann Catterick Unannounced Inspection 13th December 2006 09:20 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 Ailwyn Hall Care Home DS0000055861.V324301.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.V324301.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 Position Vacant Care Home 39 Category(ies) of Dementia - over 65 years of age (13), Old age, registration, with number not falling within any other category (26) of places Ailwyn Hall Care Home DS0000055861.V324301.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Ailwyn Hall is a care home providing personal care and accommodation for 39 older people, 13 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 £393 and £475. Ailwyn Hall Care Home DS0000055861.V324301.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 and was unannounced. The inspection visit took place on 13th December 2006 and took place over a period of 8 hours. The proprietor of the home has appointed a new manager and significant improvements have been made to the quality of care provided. The inspector was able to tour the premises, speak with the manager, deputy manager, staff, service users, relatives and a health professional. Care plans, staff files and some policies and procedures were also inspected. In conclusion there have been significant improvements to the quality of care provided and it is expected that this will continue. What the service does well: What has improved since the last inspection? Ailwyn Hall Care Home DS0000055861.V324301.R01.S.doc Version 5.2 Page 6 The proprietor has appointed an experienced manager who is improving the quality of care provided within the home. The home has its own improvement plan that is based on previous requirements and is focussed on improving services. The care plan format has improved and is now easier to understand and has much more information. The staff have received further training and are being managed and supported. This is having a positive impact on the quality of care provided to service users. “There is a good staff team and they give 110 .” Comment from a staff member. Staff were seen to care for service users in a way that promoted dignity. “Very nice girls.” “Treated with respect, very helpful.” Comment from service user. “Care good, very good.” Comment from a service user. The manager has encouraged more activities in the home and service users clearly have the opportunity to become involved in social activities or have individual time with staff if they chose to do so. There have been less slips, trips and falls than at the previous inspection. Manual handling assessments were seen in care plans. There has been some improvement to the environment. What they could do better: The home has only two baths that are used by service users and this is not really sufficient for 39 service users. The grounds are not easily accessible to service users. Window restrictors need to be put on some of the upstairs windows. Permanent signage needs to be provided in the home, especially in Emily unit. Not all areas of the home were free from any offensive odours. Ailwyn Hall Care Home DS0000055861.V324301.R01.S.doc Version 5.2 Page 7 The laundry equipment is not sufficient as there is only one washing machine and if this breaks down, as on the day of inspection, dirty laundry soon mounts up and can become a health and safety hazard. 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.V324301.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.V324301.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): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prior to admission prospective service users are assessed to ensure that their needs fall within the registration of the home and that these needs can be met. The home does not offer intermediate care. EVIDENCE: Prior to a prospective service user being admitted to the home the manager, or senior member of staff, visits the person and completes an initial assessment to ensure their needs can be met within the home. Assessments from placing social workers and health professionals are asked for. Evidence of these was seen on file. Some service users needs have significantly changed since admission and the manager has asked that social service reassess these people. Not all of these reassessments had taken place at the Ailwyn Hall Care Home DS0000055861.V324301.R01.S.doc Version 5.2 Page 10 time of the inspection visit. At the time of the last inspection the assessment was incorporated within the care plan making it difficult to assess what information had been received prior to admission. This has now been changed to enable the reader to know what information was received prior to inspection. Ailwyn Hall Care Home DS0000055861.V324301.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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of service users were being met on the day of inspection. EVIDENCE: The new manager has devised a care plan format that is a vast improvement on the previous care plans. The new care plans include a photograph and a ‘snapshot assessment’ as a front page. This informs the carer of the way an individual needs to be cared for. Within the rest of the care plans information is given in much more detail and is presented in a format that is easy to read, offering useful and relevant information. For example the care plan has a good ‘social assessment’ page’ giving information about family history, previous occupation and hobbies and interests. Within the care plan there is a page that identifies goals, i.e. has an active mind and needs stimulation with the aim is to prevent boredom and maintain an interest in life. This was seen Ailwyn Hall Care Home DS0000055861.V324301.R01.S.doc Version 5.2 Page 12 as good practice. The written format is in place and the manager now needs to ensure that staff follow this more person centred way of working. Not all the bedrooms on Emily unit had a call bell. At least one had a pressure floor mat but no other assisted technology was being used. The inspector is still concerned that a service user in bed would not be able to ring for assistance if need be. The manager needs to ensure that a person centred system assessment is made for all service users to ensure that staff are aware of when service users needs assistance, particularly during the night. A requirement has been made in this area. Those service users spoken to were satisfied with their care and felt that their care needs were being met. A community health worker spoke with the inspector and felt that the health care of service users had improved. It was felt that since the new manager has been appointed general improvements in the home had been made and that staff and residents were much happier. The administration of medication was observed and this was done in a competent way. The medication room has been decorated and a new fridge was in place. At the last inspection over ordering was taking place and this is no longer the case and the home now has a way of monitoring the ‘brought forward’ medicines. All staff who administer medication are trained to do so. At the last inspection there were some concerns that service users were not always treated in a way that protected their privacy and promoted their dignity. Service users on Emily unit now have access to their bedrooms all day if this is their preference. All staff involvement with service users was carried out in a way that promoted dignity and protected privacy. Staff were seen talking and interacting with service users throughout the day. Ailwyn Hall Care Home DS0000055861.V324301.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 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There has been improvement in the daily and social activities provided to service users. EVIDENCE: Since the last inspection the manager has had a staff meeting with all care staff to discuss the different types of activities that could take place within the home. Fireworks party, Pudsy tea party, pink day, memory joggers, arts and crafts, reminiscence group and weekly film show were some of the activities that had taken place. The manager is also encouraging staff to spend more one to one time with service users and evidence of this was seen on the day of inspection. The home now has the ‘Ailwyn Hall Newsletter’ to inform service users and their families what is going on within the home. Adult colouring books had been purchased as well as quiz/crossword books. Those service users spoken to said that there were activities going on in the home with one saying “there is always something to do.” There has been improvement in this area. Relatives and friends are always made welcome within the home. Ailwyn Hall Care Home DS0000055861.V324301.R01.S.doc Version 5.2 Page 14 The new manager is encouraging service users to have more control over their own lives and to give service users more choices in their day to day lives. The environment on Emily unit does not encourage independence due to the lack of signage. The home has been unsuccessful in appointing a permanent cook although the post has been advertised and one applicant was appointed but then changed their minds. The home is using agency catering staff to fill this gap and the present cook/chef appears to be providing good quality food. The manager hopes to secure a permanent cook as soon as possible. Service user’s comments about food were generally positive. On the day of inspection one service user on Emily unit was choosing not to sit at the dining table and was walking around the dining area and lounge. A staff member was trying to encourage the service user to sit down and eat his meal. This service user’s nutritional needs may have been best met with the provision of finger foods therefore allowing him to eat and wander round. Much has been written about the nutritional needs of service users with dementia and the manager needs to ensure that the care and kitchen staff have the relevant information and knowledge in this. A recommendation has been made in this area. The dining area within Rosie unit offers a comfortable place for service users to eat. Within Emily unit the large dining/lounge area has been divided, with laminated flooring in the dining area. There are not enough places for all service users to sit at the dining table if they choose to do so and some of those service users sitting in their armchairs did not look particularly comfortable whilst eating lunch. . A recommendation has been made in this area. Since the last inspection all of the old plastic mugs have been disposed of and service users drink out of cups or mugs, depending on preference and/need. It was noted that on Emily unit serviettes and drinks were not offered at lunchtime. A recommendation has been made in this area. Ailwyn Hall Care Home DS0000055861.V324301.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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a policy and procedure to protect service users from abuse. Service users and their families have the information required to inform them of how to make a complaint. EVIDENCE: The adult protection policy was seen on the day of inspection. Some of the information within the policy needs updating. Staff spoken to were aware of the whistleblowing policy and were clear that they would always report poor practice. The home has a complaints procedures and this is included in the Service User Guide. One visitor who was spoken to had made a complaint to the home and informed the inspector that this had been dealt with appropriately. Ailwyn Hall Care Home DS0000055861.V324301.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, 21, 22, 25 and 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There has been some improvement in this area and it would be expected that at the next inspection the outcome for this area would be at least adequate. EVIDENCE: The front entrance hall has been decorated and nightlights have been placed outside the building to give staff and visitors light when going to and from the home from car park area. The home has large grounds but the shingle driveway and car park area does not offer easy access. There is a pathway running around the home, however a ramp has been built outside a bedroom that stops anyone else continuing on the path. A requirement has been made in this area. On entering Emily unit there was a strong smell of urine within the entrance to the unit. There have been some improvements within Emily Unit. The Ailwyn Hall Care Home DS0000055861.V324301.R01.S.doc Version 5.2 Page 17 lounge/dining area has been re carpeted with a more suitable carpet and the dining space now has laminated flooring. The manager informed the inspector that some signage had been used but a service user had peeled this off the doors. The manager needs look at an alternative way of identifying different areas as service users need clear signage with regard toilets, bathrooms and bedrooms. A requirement has been made in this area. There is no handrail in the corridor on Emily unit and this does not encourage safe mobility. A requirement has been made in this area. The home has four bathrooms although only two are used. A downstairs bathroom is not usable and an old fashioned sit in bath is not used. This is not adequate for 39 service users. . A requirement has been made in this area. Some of the toilet floors have been re surfaced. An upstairs toilet did not have a sink for hand washing therefore not promoting good infection control. Some of the corridors are not well lit with either dull lighting or low watt bulbs. This does not promote safety or make corridors a welcoming place. Some light fittings do not have lampshades. A recommendation has been made in this area. Staff have a new staff room and the staff toilet has been decorated. The boiler room within the first floor of Rosie wing, that has a sign ‘keep locked’ on the door, was unlocked. As well as the boiler there were some very hot pipes in this room and this could have put service users at risk. A requirement has been made in this area. The door of a service user who was in hospital was unlocked and therefore her private space and belongings were vulnerable. A requirement has been made in this area. The laundry is small and has limited facilities, having no handing washing facility. On the day of inspection the one washing machine had broken down and washing was accruing in the laundry. Although the manager was trying to get this repaired it showed that one washing machine in a home of this size is not adequate. A requirement was made in this area. Not all areas were free from offensive odours. A requirement has been made in this area. Ailwyn Hall Care Home DS0000055861.V324301.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those staff seen and spoken to on the day of inspection appeared to be competent in their role. A significant improvement has been made in this area. EVIDENCE: Since the last inspection a manager has been appointed and the home. The home continues to have an administrator for 15 hours a week. Since the last inspection two care staff have left and no staff have been appointed. Agency staff are being used to fill vacancies and the home is hoping to appoint in the near future. The manager has devised a two week rota to enable better management of the rota. During the morning the home has five care staff on duty with one being the senior and four staff on duty during the afternoon with one being the senior. A comment was made to the inspector that none of the senior staff have English as their first language and this sometimes caused some communication problems between carers and the senior staff. On the day of inspection staff were seen to be working with service users in a competent and caring way. Service users appeared to be having their needs met. Ailwyn Hall Care Home DS0000055861.V324301.R01.S.doc Version 5.2 Page 19 The new manager has the appropriate training and qualifications to offer in house training to staff. This has meant that staff are now receiving appropriate training to ensure that they have the knowledge and skills to fulfil their role. Training files for staff are being collated and the manager has a good system for identifying what training has taken place and any gaps in staff training. Fifty percent of the twenty staff have completed NVQ level 2 with two further staff almost completed and two staff commencing in the near future. Some staff files were inspected and contained all of the appropriate documentation. Staff spoken to felt that the home had improved since the new manager had been in post. Staff felt that training was taking place and were pleased to be receiving training in dementia. The manager is aware of the new common induction standards and any new staff appointed will be inducted using these. Ailwyn Hall Care Home DS0000055861.V324301.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, 32, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has improved significantly since the appointment of a new manager. There is still opportunity for further improvement with regard some health and safety issues. EVIDENCE: The Proprietor has appointed a new manager who plans to make application to become the Registered Manager of the home. She has the appropriate qualifications, skills and knowledge to fulfil her role and there have been significant improvements in the service since her appointment. Staff spoke positively about her saying that there had been improvements in the home and staff and service users were happier. All staff spoken to felt that training was supported and promoted. Ailwyn Hall Care Home DS0000055861.V324301.R01.S.doc Version 5.2 Page 21 The manager has only been in post for a short time but has already begun to look at quality assurance within the home. This area will be looked at in more detail at the next inspection. The Proprietor now completes regulation 26 reports. Some small amounts of service users money are looked after by the home. The money is stored securely and an audit of some of the looked after money was completed by the inspector. This was found to be in order and all transactions are recorded and double signed for. Supervision has started to take place and the manager intends for this to happen on a regular basis. Staff meetings have been taking place on a regular basis. Fire records were inspected and up to date with evidence of regular drills. The boiler room on Rosie unit was unlocked and this posed an unnecessary risk to service users. A requirement has been made in this area. The manager will ensure that all health and safety training takes place and is kept up to date. Since the last inspection temperatures at water outlets have been adjusted to be as near to 43 degrees as possible. There are still radiators in a bathroom and toilet that are not covered. Some first floor windows still need window restrictors. A requirement has been made in this area. There amount of slips, trips and falls has decreased since the last inspection. Within the staff toilet the water from the hot tap was very hot, too hot to put your hands under. Staff had to lift the lid of the waste paper bin with their hands as it was not a pedal bin. This did not promote good infection control. A recommendation has been made in this area. Ailwyn Hall Care Home DS0000055861.V324301.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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x 2 1 x x 2 1 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 x x 2 Ailwyn Hall Care Home DS0000055861.V324301.R01.S.doc Version 5.2 Page 23 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 OP20 Regulation 23.2 o Requirement The registered person must ensure that all communal areas of the home are accessible to service users. This relates particularly to the patio and path and garden areas. This is the second time this requirement has been made. The previous time scale for action was 01/01/07 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 and the lack of call bells or other assisted technology in the bedrooms. The registered person must ensure that there are sufficient numbers of usable bathing facilities within the home. The registered person must ensure that when a service user is in hospital their private accommodation is made secure. The registered person must DS0000055861.V324301.R01.S.doc Timescale for action 01/04/07 2. OP22 23(2) 01/02/07 3. OP21 23.2j 01/04/07 4. OP24 12.4a 01/02/07 5. OP25 13.4c 01/02/07 Page 24 Ailwyn Hall Care Home Version 5.2 ensure that all areas of the home that service users have access to have been appropriately risk assessed and arrangement made to minimise risk. This relates particularly to the concerns with regard window restrictors and the uncovered radiator in one of the upstairs bathrooms. This is the second time this requirement has been made. The previous time scale for action was 01/01/07 6. OP26 16 k The registered person must 01/02/07 ensure that all areas of the home are free from offensive odours. The registered person must 01/02/07 ensure that the laundry equipment has the capacity to meet the needs of service users. The registered person must 01/02/07 ensure that all areas of the home that service users have access to a free from unnecessary risk. This relates particularly to the boiler room on the first floor of Rosie unit that was found to be unlocked on the day of inspection. 7. OP26 23.1a 8. OP38 13.4a RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP15 Good Practice Recommendations That the provider ensures that there are adequate dining tables and chairs to enable all residents to sit at the dining tables for meals if they choose to do so. That kitchen staff and care staff have knowledge and DS0000055861.V324301.R01.S.doc Version 5.2 Page 25 2. OP15 Ailwyn Hall Care Home 3. 4. OP15 OP25 information with regard the specific nutritional needs of service users with dementia. This relates particularly to providing different types of food including finger foods. That serviettes and drinks are provided to service users on Emily wing at lunch time. This did not happen on the day of inspection. That the lighting in the corridors are bright and meet the needs of service users and that all light fittings have lampshades. Ailwyn Hall Care Home DS0000055861.V324301.R01.S.doc Version 5.2 Page 26 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 Ailwyn Hall Care Home DS0000055861.V324301.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!