Inspection on 06/05/06 for Ashbourne House

This inspection was carried out on 6th 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ashbourne House 08/06/07

Ashbourne House 07/02/06

Ashbourne House 03/10/05

Ashbourne House 23/03/05

Ashbourne House 15/06/04

Similar services:

Chirnside House

Keer Sands Residential Home

SignHealth

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

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

CARE HOMES FOR OLDER PEOPLE Ashbourne House 230 Lees New Road Oldham Lancashire OL4 5PP Lead Inspector Michelle Haller Unannounced Inspection 05th May 2006 09:30a 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 Ashbourne House DS0000005486.V289798.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. Ashbourne House DS0000005486.V289798.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ashbourne House Address 230 Lees New Road Oldham Lancashire OL4 5PP 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) 01616241013 0161 665 2413 Werneth Lodge Limited Care Home 35 Category(ies) of Dementia - over 65 years of age (18), Old age, registration, with number not falling within any other category (17), of places Physical disability over 65 years of age (4), Sensory impairment (4) Ashbourne House DS0000005486.V289798.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 17 OP, up to 18 DE (E), up to 4 PD (E) and up to 4 SI (E). 7th February 2006 Date of last inspection Brief Description of the Service: Ashbourne House is a large detached property, set in it’s own grounds, located on the outskirts of Lees, approximately three miles from Oldham town centre. The home is registered to accommodate up to 35 people aged 65 years or above. The majority of rooms are single and have en-suite facilities. The home has three lounges a dining room and a room used for functions. Werneth Lodge Ltd owns the home. Ashbourne House DS0000005486.V289798.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the first key inspection for the Ashbourne, meaning that all the standards considered a priority were assessed. The inspection was conducted over a period of 6 hours 30 minutes. In the course of the inspection four service users files and other records concerning the support and care of service users were examined fully. Policies, procedures and other documents concerning the running of the home were also assessed. Three service users, two service users representative and three members of staff were interviewed. The interactions between service users, their representatives and staff were also observed over lunch, during organised activities and in the course of walking about the property. A tour of the private and communal areas of the building was also undertaken. The overall impression of the home is that there have been improvements relating to the environment and activities taking place in the home. What the service does well: What has improved since the last inspection? The home has begun the introduction of meaningful, regular activities and the development of an activities co-ordinator role. Ashbourne House DS0000005486.V289798.R01.S.doc Version 5.1 Page 6 The environment of the home has improved through the instigation of more effective supervision- including the introduction of a cleaning roster- and appropriate training. Increased staffing has been provided so that the needs of the service users living in the home are better met. Areas in the home have been redecorated and new fixtures, fittings and some furniture provided and a schedule for refurbishment has been developed. The home has begun a process of consultation with service users through the Residence meetings and commencement of the quality assurance monitoring. 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. Ashbourne House DS0000005486.V289798.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashbourne House DS0000005486.V289798.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 Quality in this outcome area is adequate. The homes statement of purpose and service user guide is detailed and the information provides prospective service users with sufficient information to help them to make an informed choice about moving into the home. The home provides private service users with a terms and condition of contract ensuring that they have legal document informing them of the services and facilities to they are entitled to receive from the home. This practice needs to be extended to those who are placed by a Local Authority. The basic needs of service users are assessed prior to and immediately following admission ensuring that the home fully understands and can meet the needs of service users. This judgement has been made using available evidence including a visit to the service. Ashbourne House DS0000005486.V289798.R01.S.doc Version 5.1 Page 9 EVIDENCE: These standards were assessed through examination of the homes Service User Guide, discussion with service users and the manager and examination of completed care assessments for the most recent admissions to the home. The files chosen included the most recent admission, the longest admission, the most frail service user and one other of the manager’s choice. All the files examined contained assessments that had been completed by the social worker or care manager prior to admission to Ashbourne House. The information provided was consistently detailed and this was is an improvement on the observations made during previous inspections. The homes admission check list and needs assessment provided detailed information about the service users physical, social and psychological needs. It was apparent that the assessment process is ongoing, with certain aspects of support, such as social history and activities preferences, being updated and added to in accordance with the improvement or deterioration of the service user. The information from the assessment and checklist is then brought together through development of a care plan and, on occasion, risk assessments. The assessments for the most recent admissions were detailed and provided a full picture of the needs of the services users including special diets, emotional care and specialist nursing or medical needs. Copies of the service user guide were noted in a number of bedrooms. Discussion with service users and observations made throughout the day demonstrated that activities now take place that was more in keeping with the information provided on admission. Service users were keen to confirm that they were provided with sufficient information about the home, and that all steps were taken to help them settle into the home and comments included: ‘Visited the home before moving in ... Yes everything was explained-and I told them all about myself … no rules really the staff are jolly good’. Friends and relatives who were interviewed were keen to testify that the home made every effort to help service users to settle and feel at home. Ashbourne House DS0000005486.V289798.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11 Quality in this outcome area is ‘Adequate’. The information contained in care plans consistently provides sufficient information so that care-staff know what actions to take in order to promote the health and wellbeing of service users. The introduction of specialist assessments in response to changing needs does not always occur, however the intervention and support of health care professionals is provided as needs are identified. The homes policy and procedures for dealing with the administration and storage of medication is safe, however these guidelines are not followed and therefore service users are at risk of being given medication at the wrong time. The care staff ensure that service users are able to maintain their privacy and dignity at all times. Service users who are dying are treated with care and compassion ensuring that they are pain free and any distress alleviated or kept to a minimum. This judgement has been made using available evidence including a visit to the service. Ashbourne House DS0000005486.V289798.R01.S.doc Version 5.1 Page 11 EVIDENCE: In the course of this inspection four service users files were examined, along with other reports and records concerning the wellbeing and welfare of service users living in the home. Service users, relatives and a member of staff were also interviewed. Observations, throughout the day, of the interaction between service users, staff and other visitors to the home were also completed. Information in the care plans and daily record sheets demonstrated that, the majority of routine health care including dental care, opticians, podiatry, influenza vaccine, personal physical care and visits to outpatient appointments were met to a satisfactory standard. Records and correspondence also confirmed that the staff followed specialist advice. Service users were observed wearing glasses, hearing aids and using walking aids such as sticks and Zimmer frames. It was also noted that service users had been provided with pressure relieving equipment such as mattresses and cushions, however care plans were not in place to inform staff of how to manage and apply this equipment. Specialist health care monitoring and the response to this monitoring have improved, although further improvement is possible- in that not all service uses at risk of developing pressure care are being monitored through use of a recognised assessment tool, furthermore service users experiencing the effect of dementia do not have care plans detailing the specialist needs associated with the condition- for example- engaging in activities, diet, continence needs or how to deal with any distress. Records, daily reports, care plans and risk management assessments and guidance, demonstrated that those at risk of falls continue to be well monitored, with intervention put in place to promote health and reduce any risk. Actions taken included, prompt referral to the district nurses, falls clinic, continence nurse, physiotherapist or other relevant specialist. Care plans that were examined had been updated on a monthly basis. The service users and relative who were interviewed stated that the care and support had been discussed with them and they had agreed with actions detailed in the care plans. Examination and observation of the homes practice in distributing medication demonstrate that pictures of the service users had been placed on the corresponding dosette boxes; sample signatures of all staff that administered medication had also been placed on the front of the Medication Administration records (MAR) file. However it also became evident that the times medication was to be administered was inexplicably missing from the MAR sheets used in the home on the day of inspection. Ashbourne House DS0000005486.V289798.R01.S.doc Version 5.1 Page 12 This was discussed with the manager who agreed to rectify the problem immediately. Observation and discussion with service users and relatives indicated that all care was provided in private, respectful and discreet manner. In response to questioning in this area one service user commented -. ‘Staff keep me covered’. Discussion with staff confirmed that service users receive good palliative care at Ashbourne House. Staff described the training they had received in respect of identifying levels of pain and distress. Staff also identified the role of district nurses and doctors in the process, stating that the district nurses and doctors visited the service user on a daily basis for as long as was necessary. Staff explained the importance of a calm environment and to direct all conversation to the service user. Care staff also indicated that palliative care included one-to-one support at all times, and on occasion extra staff have been roistered to ensure that this has been provided. Descriptions of care provided included: ‘I would inform senior staff, ensure privacy, give plenty of attention, stay with the person, staff make sure they are comfortable- not scared or in pain and I would ask questions about when to alert elatives. General comments from service users included; ‘what-ever you want you don’t have to be frightened to ask’, and ‘They’ll do anything for you’. Ashbourne House DS0000005486.V289798.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 Quality in this outcome area is adequate. The home attempts to promote the maintenance and development of thinking skills and physical ability through its’ provision of a variety of in-house activities. A sense of wellbeing and continued belonging is promoted as service users are supported and enabled to maintain contact with friends, family and the local community. A sense of control, autonomy and value as an individual is promoted as service users are, for the most part, enabled to exercise choices in their lives. The dietary needs of service users are well catered for with a balanced and varied selection of food available that meets the service users tastes and choices. This judgement has been made using available evidence including a visit to the service. Ashbourne House DS0000005486.V289798.R01.S.doc Version 5.1 Page 14 EVIDENCE: Service users were, for the most part, pleased with the activities that had recently been introduced into the home. Comments included: “I have enjoyed ball games and bingo.” Service users were also observed enjoying a bingo session followed by a manicure session during the afternoon of the inspection. The manager has introduced an activities calendar that is flexible. Activities equipment including a giant ‘Connect 4’ game, floor puzzles, darts, and arts and crafts materials were noted. Other activities include armchair exercises, and sing-along. The manager stated that the Parish Whit Walk was due to begin from the home and there was an ongoing relationship with the local Church of England minister. Records indicated that the activities organiser had arranged a meeting with resident to discuss things they would like to do. And this included bingo, skittles, and the planting of a sensory garden. It might also be appropriate for her to assist this process by providing a list of suggestions that includes entertainers from outside and excursions, as all activities are currently based at Ashbourne House, furthermore with the exception of religious services and festivals, all activities are lead by care staff. Discussion with staff also indicated that activities occurred more frequently and the daily reports confirmed that activities were taking place and the response of service users was noted. The training calendar includes the course ‘Activities for people living in a residential home’ provided by Age Concern. The activities co-ordinator will be enrolled on the next available place. Whilst being interviewed one service user commented that he would enjoy excursions and another stated that he has spoken about card games in the past but these have not been purchased as yet. Currently service users provide their own magazines and books. Service users and relatives stated that visiting could be at any time that was convenient to them. During the inspection it became evident that visits took place either in the lounge areas or bedrooms, according to the wishes of the service users. It was also observed that friends and relatives were treated with curtsey and respect when they visited during periods when the service user was not immediately available such as at meal times. It was clear that the admission process identified that service users were called by their preferred names. Random checks of clothing confirmed that the laundry system ensured that service users wore their own clothing. Ashbourne House DS0000005486.V289798.R01.S.doc Version 5.1 Page 15 On the day of inspection all service users were clean, neat and tidy. The dining room at Ashbourne provides a comfortable and clean dining experience. It was noted that all service users now sit in this area at all meal times. The meals provided at Ashbourne House are evaluated through a computer programme that should ensure that they are nutritionally balanced. The midday meal on the day of inspection was fish and chips or mash and fruit salad, the teatime meal was to potato hash and beetroot or sandwiches followed by fruitcake. The store larder was well stocked with a large variety of basic ingredients for home cooking and a pleasingly limited range of readymade and tinned foods. Fresh vegetables were also in store. The fridge and freezers were well stocked with meats, bread and vegetables. Fresh fruit juice, squashes, tea, coffee, cocoa and horlicks were also readily available. In the afternoon of the inspection the cook was observed asking service user to make choices for the teatime meal. Notes made at the service users meeting identified that they had expressed a wish for salmon to be included on the menu and this has been placed on the next food order. The menu also indicated that meals were varied and culturally sensitive. Service users were very enthusiastic about the meals provided in the home and confirmed that a choice was offered on daily basis. Service users indicated that food and snacks were varied and plentiful. Food is’ very good - I can ring for anything, snacks or hot or cold drinks’ One relative commented ‘It’s all very good’ about the overall care in home. Ashbourne House DS0000005486.V289798.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. Complaints are taken seriously and diligently dealt with in the home. Steps are taken to ensure that service users are protected from abuse. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Examination of the complaints records maintained by the home demonstrated that, complaints were given serious consideration. Discussion with the manager and owner confirmed that they were clear about incidences that needed to be investigated following the Protection of Vulnerable Adults guidelines that complaints that could be initially dealt with ‘in-house’. The complaints policy fully meets the minimum standards. Service users and relatives who were interviewed stated that they would discuss any concerns with a member of the care staff. Service users who were interviewed had not had any cause for complaint, however each indicated that they felt safe in the home, and able to discuss any problems openly and with the confidence that any problems would be quickly solved. Ashbourne House DS0000005486.V289798.R01.S.doc Version 5.1 Page 17 The homes adult protection policy and guidelines are detailed and in line with those developed by the local authority however an investigation into an allegation of abuse was not completed in line with these guidelines. Staff were clear about the behaviours that constituted abuse and were also clear and confident about their role in adult protection and highlighting abusive or potentially abusive actions or omissions. The staff interviewed had received in-house training and some training through completion of the NVQ level 2. Staff should also attend the Adult Protection training provided by the local authority as this will enhance their knowledge and make them fully aware of what is expected of them in relation to adult protection. Ashbourne House DS0000005486.V289798.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 23 , 24 and 26 Quality in this outcome area is adequate’. The private and communal accommodation in the home provides a comfortable, clean, homely and welcoming place for all service users. The home provides sufficient equipment to promote the independence and safety of service users as they move around the home. The equipment in some areas of the home fail to promote the safety of services users. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The inspection process included a tour of the communal and private areas. Time was also spent in the communal areas talking to service users and observing their movements. Ashbourne House DS0000005486.V289798.R01.S.doc Version 5.1 Page 19 During the tour it was observed that of the exterior of the building and grounds were well maintained. The garden areas were tidy and accessible to service users. The company employs a maintained man and he carries out and arranges for maintenance of equipment and services as necessary. A brief discussion with the maintenance man confirmed that he had been provided with a scheme of work that included the redecoration of a number of bedrooms and some re-carpeting. The radiators in a significant number of rooms were not covered, and neither was there satisfactory risk assessments precluding the need for covers. This was discussed with the manager, the owner and the maintenance worker. The majority of bedrooms have en-suite facilities. In addition there are toilets, washbasins and specialist bathing facilities on each floor of the property. In the course of the inspection most bedrooms were entered and it was noted that many had been furnished with easy chars, ornaments and wall pictures had been put up. Discussion with staff and service users indicated that some effort has been made to assist service users in personalising their rooms with pictures, ornaments or other items. Service users who were interviewed were satisfied with their rooms many of which had been personalised with their own belongings. Furthermore one service user commented that staff were in the process of helping her to decorate and furnish her room with items from her home and through shopping for personal items. A cleaning roster has been introduced and the home was clean and free from offensive odours at the time of inspection, furthermore most surfaces were clean and free from obvious stains. Since the previous inspection the carpet in the main lounge has been replaced. All the carpets were clean and maintenance carried out where required. The furniture and fixtures and fittings in the home were clean and pleasant to use. Commodes were clean and many appeared to have been re-varnished. The home was free from unpleasant odours. Ashbourne House DS0000005486.V289798.R01.S.doc Version 5.1 Page 20 Ashbourne House DS0000005486.V289798.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. The ability and ratio of staff available in the home ensures that services users emotional, physical or social needs are met. The provision of induction training and specialist training needs to be increased and the outcome for service users effectively monitored, thereby improving the quality and effectiveness of care and support provided. The home operates a recruitment and selection process that provides full safeguard to service users against abuse. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The standards concerning staffing were inspected through discussion with staff, observation of staff interaction with services users and examination staff files for four care staff and examination of the duty roster. The staff roster has been revised and the staff compliment was one manager; four care assistants, the cook and a one domestic staff. Examination of the roster indicated that this was now the established staffing level. This confirms an increase in staff ratio, which has had a positive effect on the care, support and atmosphere in the home. Ashbourne House DS0000005486.V289798.R01.S.doc Version 5.1 Page 22 It was observed that service users were attended to more quickly and the atmosphere in the home was more relaxed and calm. Furthermore staff had time to occupy and sit with service users who required extra attention and comfort. It was also noted that staff were aware of those that needed attention and were prepared to intervene and provide effective emotional support spontaneously. The provider confirmed that staff have completed training courses including manual handling, dementia care, infection control- including Better Food, Better Business (provided by the Health and Safety regulators), National Vocational Qualification (NVQ) in care levels 2, 3 and 4 and a course entitled ‘Yesterday-Today-Tomorrow’. The observation of staff practice, discussion with staff and records made during supervision demonstrated that this training was having a positive effect on practice. Further specialist training and additional first aiders are required however before this standard is fully met. Four staff files were examined and it was noted that a Criminal Record Bureaux Check (CRB) had been completed and two references and proof of identification was in place for each. Ashbourne House DS0000005486.V289798.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. The quality and effectiveness of the management in the home appears consistent and provides an environment were good practice is enabled and recognised. The quality assurance system that will enable all involved in the home to comment on the quality of the service is being developed. The finances of services users are safeguarded reducing the risk of financial abuse. The home needs to provide additional training and safety equipment to ensure that service users are fully safeguarded. This judgement has been made using available evidence including a visit to the service. Ashbourne House DS0000005486.V289798.R01.S.doc Version 5.1 Page 24 EVIDENCE: The manager has commenced the NVQ 4 registered management award, however, she is an experienced deputy manager of another home. The inspection process demonstrated her abilities to manage the home. Supervision records, discussion with staff, services and observations made during the inspection indicates that the service provided at Ashbourne is now more adequately monitored. This is evident from an improvement in the cleanliness of the home and general monitoring of the environment, the updating of required systems such as the medication protocol, effective staff supervision and an improvement in the overall support provided to service users. Individual receipts for all transactions made by service users continue to be maintained ensuring that all transactions can be verified. The manager has completed accredited first aid training. The home training calendar identifies that the manager recognises the need for additional staff to receive accredited first aid training. Through cross referencing accident records with the initial treatment provided by staff it was possible to identify that some staff were aware of the appropriate action to take following certain types of accidents such as pumps and falls. The need for accredited training, however, remains outstanding. A means of analysing the accidents recorded has, however, been established. Radiator covers need to be installed. Records confirmed that gas and electrical appliances and services were regularly checked and maintained. Fire safety equipment was regularly checked and fire drills completed in accordance with guidance from the Fire Service. Ashbourne House DS0000005486.V289798.R01.S.doc Version 5.1 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 1 2 3 4 5 6 Score ENVIRONMENT Standard No 19 20 21 22 23 24 25 26 Score 3 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X 3 3 3 2 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 2 Ashbourne House DS0000005486.V289798.R01.S.doc Version 5.1 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP2 Regulation 5 Requirement The registered person must ensure that they are able to demonstrate that all service users have been information about the terms and conditions in respect of accommodation and a contract stating the service and facilities the home will provide. The registered person must be able to demonstrate that appropriate monitoring of health needs and the care provided, continues for all service users. The registered person must ensure that information about the medication to be administered in the home is clear and easy to understand. The registered person must continue to consult service users about the programme of activities arranged by or on behalf of the care home. The registered person must ensure that the adult protection training is provided to all staff. Timescale for action 01/09/06 2. OP8 14(2)(b) 01/09/06 3. OP9 13(2) 01/06/06 4. OP12 16 (m)(n) 01/09/06 5. OP18 13 (6) 01/07/06 Ashbourne House DS0000005486.V289798.R01.S.doc Version 5.1 Page 27 6. OP28 18 7. OP33 24 8. OP38 13 (4) 9. OP31 8 The registered person must ensure that persons employed to work at the care home continue to receive training appropriate to the work they are to perform. The registered person must complete the process of Quality Assurance that had previously commenced in the home. The registered person must ensure that all radiators in the home are covered or have a guaranteed safe surfacetemperature. The registered person must put forward to CSCI a suitable candidate to become registered manager. 01/09/06 01/09/06 01/09/06 01/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ashbourne House DS0000005486.V289798.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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. 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