Inspection on 09/05/06 for Ash-Croft House Care Home

This inspection was carried out on 9th May 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.

Other inspections for this house

Ash-Croft House Care Home 12/06/08

Ash-Croft House Care Home 10/12/07

Ash-Croft House Care Home 06/02/06

Ash-Croft House Care Home 25/08/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Ash-Croft House Care Home 10-12 Elson Road Formby Merseyside L37 2EG Lead Inspector Mrs Claire Lee Unannounced Inspection 9th May 2006 09:15 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-Croft House Care Home DS0000064981.V289543.R01.S.doc Version 5.1 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-Croft House Care Home DS0000064981.V289543.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ash-Croft House Care Home Address 10-12 Elson Road Formby Merseyside L37 2EG 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) 01704 874448 Cedars Care Group Limited Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Ash-Croft House Care Home DS0000064981.V289543.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service should employ a suitably qualified and experienced manager who is registered with the CSCI 6th February 2006 Date of last inspection Brief Description of the Service: Ashcroft House is a care home registered to provide nursing care for 31 older persons. The home is situated in Formby and is privately owned. The owner has other homes in the Southport area. The area around the home is mainly residential and there are local areas of interest such as the squirrel park. There are local shops directly opposite Ashcroft House and a main train and bus route within easy walking distance. The accommodation is converted from two previous houses. There are 2 main lounges, a quieter lounge, a lounge that is also used for dining facilities next to the kitchen. There are 25 single rooms and 3 double rooms, 2 rooms have ensuite facilities. 5 of the bedrooms are situated up a small amount of stairs and do not have ramps or a stair lift to access them. Residents utilising this space must be either mobile enough to climb the stairs or do not wish to leave their rooms. Many of the residents have personalised their room space and have brought items of their own furniture, which assist in contributing to the homely appearance of Ashcroft House. There are 4 bathrooms and 3 shower rooms and sufficient WCs for residents to use. There are gardens to the front and the rear of the establishment. A large car park area is located at the front of the building. Ashcroft House is a nonsmoking building and the fees for accommodation are between £475-£495 per week. Ash-Croft House Care Home DS0000064981.V289543.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one day for approximately 10 hours and 29 residents were accommodated at this time. It was an unannounced inspection (site visit). A partial tour of the premises took place and a number of the home’s care, staff and health and safety records were viewed. Discussions were held with 5 residents, 3 staff, the home’s administrator, acting manager and owner. During the inspection 4 residents were case tracked (their care files were examined and their views of the home were obtained). This process was not carried out to the detriment of other residents who also took part in the inspection process. Discussion also took place with 2 relatives. All the key standards were inspected and also previous requirements and recommendations from the last inspection in February 2006 discussed. Satisfaction survey forms “Have Your Say About …” were distributed to a number of residents prior to the inspection and some were also left for them and relatives to compete at the time of the visit. Comments included in the report are taken from the survey forms and also during the site visit. What the service does well: The home has a detailed Service User Hand Book, which is given to prospective residents and their representative. The most recent inspection report is also available for residents to view. Contracts are drawn up so that residents and their representatives are aware of the terms and conditions of the residency in the home. Ashcroft House presents with a very warm, caring environment and staff pride themselves on making residents and relatives feel welcome. This was observed during the time spent at the home. The team of staff are well established and they demonstrated a kind and caring attitude when delivering care and support to residents. Residents were pleased with the overall care they receive and general management of the home. A resident said, “The staff are very good”. Residents’ needs are assessed in full before admission and their individual care files contain sufficient information regarding health and social care to ensure the staff deliver a good standard of care. Care files are reviewed regularly with the residents and/or their representative to reflect any change in care or treatment. Those residents seen during the site visits were clean and appropriately dressed and staff interviewed understood the need for residents to exercise choice. This was discussed in relation to the routine in the home Ash-Croft House Care Home DS0000064981.V289543.R01.S.doc Version 5.1 Page 6 and also preferred activities and meals. Residents nursed in bed were observed to be comfortable and regularly attended to. The staff answered calls for assistance from residents promptly. Staff chat with residents to obtain their views of home and residents are also provided with satisfaction questionnaires to complete. Resident meetings are held. Regular quality monitoring takes place via monthly visits by the owner’s representative and a report is then forwarded to the Commission for Social Care Inspection. The residents are offered a varied social programme and the home has its own transport for outings. A resident said, “The social side is very good”. Residents were generally complimentary regarding the standard of food served and presentation of the meals. What has improved since the last inspection? What they could do better: Ash-Croft House Care Home DS0000064981.V289543.R01.S.doc Version 5.1 Page 7 The risk assessment for residents who wish to self medicate should include a list of the medicines being self administered. The complaint procedure should be displayed in the home. The home does not currently employ a maintenance man and this has affected the overall cleanliness of the building. There is also concern that every day jobs and repairs are not being undertaken when needed. The owner has stated that the home is currently advertising this position and a maintenance man from another home within the group will assist. A number of carpets in resident bedrooms are dirty and stained. They require urgent cleaning and must be replaced if the stains cannot be removed. The garden at the rear of the building is also overgrown and the grass in need of cutting. The home must ensure recruitment practices are robust to protect the residents. A POVA (Protection of Vulnerable Adult) check must be obtained for all staff prior to them commencing work at the home. Staff are monitored and supported in their work however they must receive an induction when commencing employment. The fire alarms must be subject to safety checks to ensure the health and safety of the residents. The fire safety department should be contacted with regard to the frequency of ‘in house’ checks of the emergency lighting, as they are not being carried out each month. 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. Ash-Croft House Care Home DS0000064981.V289543.R01.S.doc Version 5.1 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-Croft House Care Home DS0000064981.V289543.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2, and 3 (Standard 6 - Intermediate Care is not provided) The quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Detailed information is available to residents, relatives and visitors in the form of the home’s Service User Guide (Service User Hand Book) and contract. Pre admission assessments help ensure that the home can meet the needs of the residents. EVIDENCE: The home has a Service User Hand Book, which is given to residents and/or their representative on admission. A resident stated that she had been given all the details of the home when she arrived. The last inspection report was also available in the office for residents and their representative to view. The acting manager undertakes the initial assessment for all potential residents and where possible an assessment from social services is also obtained. Assessments for four residents were viewed; this included an assessment of a resident recently admitted. The assessments had been completed in detail with regards to health, personal and social care and this information had been used to form the basis for the plan of care. A resident who has very recently arrived at the home stated that she was settling in well and “Very pleased with Ash-Croft House Care Home DS0000064981.V289543.R01.S.doc Version 5.1 Page 10 everything so far”. She had not received the Service User Hand Book however the administrator confirmed that this would be given to the next of kin. Survey forms make reference to the home providing sufficient information regarding the service and that contracts are sent out. A contract seen had been dated and signed by a resident. Ash-Croft House Care Home DS0000064981.V289543.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9, and 10 The quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents’ health, personal and social care needs are addressed in care plans and the home’s medicine policy and procedure is adhered to. Residents are treated with respect and dignity. This ensures a good overall standard of care in the home. EVIDENCE: Residents have an individual care file, which is reviewed by a qualified member of staff with the resident and their relative/representative. The reviews are carried out o reflect any change in care or treatment and are signed by the resident where possible. Four resident care files were case tracked and care plans viewed reflected current health, social and personal needs. Residents have access to external health professionals and records were seen of external professional visits including, GP and chiropody. A resident interviewed said the staff were good at arranging appointments. The home completes a number or risk assessments with regards to nutrition, falls, manual handling and skin integrity. Where a risk had been identified the home had then implemented a care plan to meet to monitor the risk. This was discussed in relation to wound Ash-Croft House Care Home DS0000064981.V289543.R01.S.doc Version 5.1 Page 12 care. Wound care management has improved since the last inspection and staff now ensure wound care charts are completed and the care plan reflects the ongoing treatment. One wound care chart had not been updated and this was brought to the manager’s attention. The qualified staff write a daily record for each resident and care staff are also encouraged to record the care they give. Discussion with a staff member confirmed this. Comments regarding the care included: “The care is very good and the staff are here to help” (resident) “I am very happy with the care we receive (relative) “Both my husband and I are supported by the staff” (relative) “I am happy with the care” (resident) “Very good care” (relative) Staff were observed giving regular attention to residents with various aspects of personal care. Staff were comfortable in carrying out the care and clearly understood the residents’ needs. A member of the care staff referred to the good handover they receive at each shift change to ensure they are aware of the care they are to provide each day. Medicines are handled, stored and administered according to the home; policy and procedure and staff have recently attended training in medicine awareness. Residents are able to self medicate and the home ensures a risk assessment is completed for this practice. It is recommended that this also include a list of the medicines that the resident wishes to self medicate. A photograph of each resident is in place for verification purposes. Residents were observed to be treated with respect and a resident said, “The staff knock on my door before coming in”. During lunch staff offered assistance to residents who required help. This was performed in a sensitive manner. Ash-Croft House Care Home DS0000064981.V289543.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 The quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents are able to exercise choice and control over their lives and are offered a choice of well balanced and nutritional meals. EVIDENCE: Observation and discussion with residents, relatives, staff and viewing of records confirmed that the residents are encouraged to have choice and control over their lives and daily routines within the home. This was discussed in relation to choice of meals, time of getting up in the morning and retiring at night. Assessments and care plans viewed demonstrated that social interests and wishes had been recorded. A relative commented on the fact that she could visit any time and was always made welcome by the staff. An activity organiser provides activities and the home’s transport enables the residents to go out for the day. Activities include shopping, gentle exercise, bingo, garden parties and musical entertainment. Visitors have the use of the hairdressing room/chiropody room, which has chairs and a tea bar. Relatives also get Ash-Croft House Care Home DS0000064981.V289543.R01.S.doc Version 5.1 Page 14 together for a social evening at a local venue arranged by the home. A survey form completed by a resident makes reference to the home’s varied social programme and this includes, “Bingo, films, pub lunches and other outings”. The activity programme is displayed for the residents to view and choose which they wish to attend. The home presented with a warm, friendly environment. A number of residents were using the lounges however some preferred to stay in their own room and this wish was respected by staff. Residents cannot currently sit in the garden, as the grass is overgrown. This is discussed further under Standard 19 (Environment) The home is not responsible for residents’ monies; relatives/representatives deal with financial transactions. The menu was viewed and this offered a choice of well balanced meals. An alternative is available and a resident confirmed that the cook would always prepare something else if needed. The staff do ask residents what meals they would like to have and record this. The cook explained that company is looking at providing a ‘group menu’ however the home must ensure residents are consulted with regard to any changes made. The home caters for special diets including gluten free and diabetic. Comments regarding the food included: “I can ask for the meal that I want” (resident) “Staff are happy to give the main meal in the evening and a snack at lunchtime” (relative) “Breakfast is excellent and a choice is offered at tea, dinner. There is room for improvement” (resident) “I have lunch on a Sunday at the home” (relative) Ash-Croft House Care Home DS0000064981.V289543.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Potential complaints and concerns are managed well and residents and relatives have confidence that their concerns will be dealt with. Abuse policies and procedures are in place to protect the residents. EVIDENCE: The home has a complaint procedure. Details of which are given to the residents and their relatives/representative in the Service User Handbook. It is recommended that a copy of the complaint procedure be displayed in the home. The home maintains a complaint log and this evidenced details of complaints received and the investigation undertaken. Residents interviewed said they would speak with the nurses or Sui (acting manager) if they had a problem. Comments included: “I have no cause for complaint” (relative) “I have not had to make any but I know who to speak to and when” (relative) The training programme viewed showed that abuse training is provided to all staff to ensure they are aware and understand the adult protection procedures. It is recommended that the home obtain a copy of the latest Sefton Adult Protection Procedure for Vulnerable Adults. The home’s abuse policy was viewed and this contained the Whistle blowing Procedure. Staff interviewed Ash-Croft House Care Home DS0000064981.V289543.R01.S.doc Version 5.1 Page 16 stated that they would speak to the nurse in charge in the event of an alleged incident. Ash-Croft House Care Home DS0000064981.V289543.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21,22,23,24,25 and 26 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The home offers comfortable accommodation however the general upkeep and cleanliness of the home is not satisfactory and therefore residents are not currently living in a well maintained home. EVIDENCE: A partial tour of the building was conducted. The A number of residents’ rooms were viewed and the carpets were found to be dirty and stained. This poor standard of cleanliness must be addressed. The carpets require urgent cleaning and if stains cannot be removed then the carpets must be replaced. The home does not at present employ a maintenance man, the acting manager is reliant on receiving help from the other homes within the group. Day to day jobs and repairs are therefore not being carried out. This problem was discussed with the owner who stated that the home is advertising this position. A full written maintenance plan is required to prioritise the work that is required and to continue the renewal of the decor and fabric of the building. Three of the bedroom floors are linoleum and are not ‘homely’ in appearance. Ash-Croft House Care Home DS0000064981.V289543.R01.S.doc Version 5.1 Page 18 Residents are encouraged to personalise their bedrooms and bring in items such as ornaments, pictures and electrical equipment. A resident interviewed stated that she was “comfortable” in her room. Residents have their own phone if they wish. The communal areas are pleasantly furnished and provide sufficient space for the residents to have their meals, sit and chat, watch TV, take part in entertainment or meet their visitors. A resident said, “It is a very nice place to live”. Bathrooms have bath hoists and residents also have the use of adapted showers. Hot water temperatures are recorded by staff prior to bathing residents to ensure the water is delivered to a safe temperature. Residents have the use of a call system with a hand held buzzer however one resident did not have one and this was brought to the manager’s attention. Pressure relieving mattresses were seen on a number of beds and bed rails had bumpers to minimise the risk of injury to the resident. The home has car parking to the front and an enclosed garden to the rear. Residents cannot use the garden at present as the grass is very overgrown and in need of urgent attention. With the summer approaching residents must be able to sit in the garden in comfort. This was discussed with the owner at the site visit. There is a small patio area with furniture. The laundry room is situated in the basement. Staff have access to gloves and aprons and infection control is discussed during induction and incorporated in the home’s training plan and NVQ. Emergency lighting is provided throughout the home and subject to a safety check by a qualified engineer. Records were seen to confirm this however it is also recommended that the home contact the fire safety department for advice regarding the frequency of ‘in house’ checks. A number of kitchen cupboards are broken and in need of repair. It was explained that the kitchen is to be replaced and this planned work should be incorporated in the home’s maintenance plan. Ash-Croft House Care Home DS0000064981.V289543.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 The quality in this outcome area is adequate This judgement has been made using available evidence, including a visit to this service Staff require an induction to ensure they are equipped with the skills to meet the needs. Recruitment procedures are not robust to protect the residents. EVIDENCE: The staffing rota viewed for the week of the inspection and this confirmed that that a sufficient number of staff are employed to care for the residents. A registered nurse was on duty in the morning with five care staff, a cook, two domestics, general assistant to help in the kitchen, administrator and acting manager. Five care staff were on duty in the afternoon. The home has a training matrix and this evidenced courses attended and those being accessed at this present time. Many of the courses involve the completion of a workbook and staff are then given certificates. Staff files contained an individual training record however these have not been kept current. A record of induction had also not been recorded for two members of staff. Courses are arranged in safe working practice area including manual handling, first aid, food hygiene, health and safety and infection control. Staff are also encouraged to undertake further studies to enhance their knowledge of the older client group, for example, abuse, risk assessment, diabetes and dementia care. NVQ training at Level 2 and Level 3 is ongoing and the majority of staff have achieved a qualification in care. Staff interviewed were complimentary regarding the standard of training in the home. Ash-Croft House Care Home DS0000064981.V289543.R01.S.doc Version 5.1 Page 20 Following the change in ownership the staff files have been updated. Four staff files were viewed and there was no record of induction training in two files. This must be given within a six-week period for new employees. With regards to recruitment, application forms had been completed, two written references obtained and a photograph was on file for each employee. Recruitment procedures are however not robust as a member of staff commenced work at the home prior to the vulnerable adults (POVA) check being received. Staff must not be employed until a POVA First check has been obtained pending a CRB (Criminal Record Bureau) enhanced disclosure. This information was available in the other files examined. Staff are given contracts of employment, a handbook and job description. Residents interviewed stated that they were happy with the staff and thought they were caring and kind. Comments included: “The staff have become my friends and I couldn’t cope without them” (relative) “There is always someone to help” (resident) “ The staff always do everything for me” (resident) Ash-Croft House Care Home DS0000064981.V289543.R01.S.doc Version 5.1 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,34,35 and 38 The quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. An acting manager continues to work closely with the owner however a new manager is being appointed this month. The new manager must then apply to be registered with the Commission for Social Care Inspection to ensure she is fit to run the home and maintain standards of care. The health and safety of the residents has not been protected, as fire prevention records were not up to date. EVIDENCE: The home has employed a new manager who is due to start work at the home this week. The acting manager will continue to work along side the manager and owner to facilitate the change. The acting manager has continued to manage the home and staff and residents have been complimentary regarding Ash-Croft House Care Home DS0000064981.V289543.R01.S.doc Version 5.1 Page 22 her open management approach. Staff receive supervision and supervision records are maintained. A number of the home’s maintenance certificates and contracts were examined and these were all in date. The home’s fire logbook did not however evidence a check of the fire alarms since 18th April 2006. This safety check use to be carried out by the home’s maintenance man and since his departure no member of staff has carried this out. Staff were very unsure how to complete the test and how often the checks should be undertaken. This was discussed with the owner and during the inspection a satisfactory safety check was performed. The home’s fire prevention equipment is subject to a full maintenance contract and staff receive fire prevention training. As previously stated the home is not responsible for residents’ monies. The home’s insurance cover was displayed in the main hall and was in date. A quality assurance system that asks residents for their point of view is instrumental in the running of the home and the owner’s representative undertakes monthly unannounced visits to view the home and meet residents. The reports from these visits are forwarded to the Commission for Social Care Inspection. Residents and relatives commented on the good management in the home and that “the manager goes to a great deal of trouble”. Resident and staff meetings are held. Staff have access to the group’s policies and procedures for safe working practices. The accident book records any incident that affects the well being of the resident. Recent entries were examined. Ash-Croft House Care Home DS0000064981.V289543.R01.S.doc Version 5.1 Page 23 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 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 3 3 3 X 2 Ash-Croft House Care Home DS0000064981.V289543.R01.S.doc Version 5.1 Page 24 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. 2. 3. 4. 5. 6. 7. Standard OP19 OP19 OP19 OP29 OP30 OP31 OP38 Regulation 23 23 23 19 18 8(1) 23 Requirement A full maintenance plan must be developed and adhered to The carpets that are stained and must be cleaned or replaced if required The grass must be cut to ensure the garden is accessible for the residents All staff must have a POVA check before commencing work at the home Staff must receive an induction when they start work at the home The new manager must submit an application to be registered manager. Fire alarms must be checked and recorded Timescale for action 09/07/06 24/05/06 24/05/06 24/05/06 24/05/06 09/06/06 24/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Ash-Croft House Care Home DS0000064981.V289543.R01.S.doc Version 5.1 Page 25 No. 1 2. 3. 3. 4. Refer to Standard OP9 OP16 OP18 OP19 OP25 Good Practice Recommendations The risk assessment for self medication should include a list of the medicines being self administered A copy of the complaint procedure should be displayed in the home The home should obtain a copy of the latest Sefton Adult Protection Procedure for Vulnerable Adults Consideration should be made to replacing the lino floors in three of the bedrooms The fire safety department should be contacted for advice regarding monthly checks of the emergency lighting. Ash-Croft House Care Home DS0000064981.V289543.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: 0845 015 0120 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 Ash-Croft House Care Home DS0000064981.V289543.R01.S.doc Version 5.1 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!