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Inspection on 11/10/05 for Ashbourne Residential Home

Also see our care home review for Ashbourne Residential Home for more information

This inspection was carried out on 11th October 2005.

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

What has improved since the last inspection?

Since the last inspection an admin person has been appointed to relieve the manager of some administration tasks. Re-decoration has been carried out in lounges, new chairs have been purchased. A number of bedrooms have also been redecorated. Factions and conflict within in the staff team have been and are still being addressed. Relationships do appear to have improved. The home has improved in all areas of record keeping. The manager and staff team have put a lot of energy into improving and maintaining care plans and other records. It is evident that staff, at all levels, are gaining confidence in using and completing the homes records and documentation.

What the care home could do better:

Although record keeping has improved, personal care delivery and daily food consumption records still require attention to ensure that they are completed with consistency. Medications require more attention to ensure total safety to residents. All prescribed creams must be signed for. Prescribed medication must be available at all times. Plans must continue for all staff to receive accredited medication training. Redecoration in some areas is needed this to include bedrooms which have not recently been decorated, window frames and sills, toilets and bathrooms. Carpets in a number of rooms where an odour persists must be replaced. The laundry floor is also in need of replacement. Staffing levels must be increased for the morning shift to allow more flexibility and assistance to those who require help with their breakfast. The organisation must ensure that the manager commences N.V.Q training at level 4 as soon as possible.

CARE HOMES FOR OLDER PEOPLE Ashbourne Residential Home Lightwood Road Dudley West Midlands DY1 2RS Lead Inspector Mrs Cathy Moore Unannounced Inspection 11th October 2005 07:35 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 Residential Home DS0000024969.V257232.R01.S.doc Version 5.0 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 Residential Home DS0000024969.V257232.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ashbourne Residential Home Address Lightwood Road Dudley West Midlands DY1 2RS 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) 01384 242200 01384 242458 Southern Cross Care Centres Limited Mrs Ann Margaret Gomersall Care Home 38 Category(ies) of Dementia (6), Old age, not falling within any registration, with number other category (32) of places Ashbourne Residential Home DS0000024969.V257232.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. That the number of service users with Dementia is 6 That the additional staffing resources be secured prior to any service user being admitted. That no more than 2 persons who are wheelchair users are accommodated (rooms 30/34) within the additional 10 places. One service user in the category of OP may also be A(E). This will remain until such time that the current service users placement is terminated. One service user with sensory impairment elderly SI(E) to be admitted. This wil remain until such time that the current service users placement is terminated. 20/04/05 Date of last inspection Brief Description of the Service: Ashbourne care home is a detached property. It is situated off the main Sedgley to Dudley Road. The home is located in a residential area. It is close to a main bus route and a number of small shops. The home has large gardens to the front and rear and a car parking area. The home is registered with the Commission for Social Care Inspection (CSCI) to provide care to a maximum of 38 residents falling within the category of Old Age. Six of these places at any one time can be offered to older people who have a diagnosis of dementia. The home comprises of two floors. Communal space is on the ground floor offering a number of different lounges and a dining room. The ground floor houses the reception area, a number of bedrooms, bathing facilities, the main office, the kitchen, laundry and toilets. The first floor accommodates bedrooms, toilets and bathing facilities. The staff group comprises of a manager, deputy manager, seniors and care assistants, a handyperson, an activities co-ordinator, catering, laundry and domestic personnel. Ashbourne Residential Home DS0000024969.V257232.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one inspector on one day, between 07.25 and 15.10 hours. The inspection was carried out as the second of the homes two routine statutory inspections for this year. Three residents’ were chosen for case tracking purposes. This process involved assessing care plans, daily notes, records pertaining to health care access and activity provision. A total of seven residents’ and one staff member were spoken to. The premises were randomly assessed this included viewing bathrooms, toilets, the laundry, lounges, dining room and garden. Two staff files were perused this process included the assessment of application forms and other documents required by legislation. Activity provision, medication administration and meal times were also briefly observed. Records pertaining to servicing of equipment and fire equipment were assessed along with risk assessments. Not all standards were assessed during this inspection for a full overview of service delivery this report must be read in conjunction with the previous inspection report dated the 20 and 21st April 2005. What the service does well: The home is owned by a large organisation providing help guidance and support where needed. The manager has been in post for a number of years as have a number of staff giving continuity and consistency of care to the residents’ accommodated. The manager has a commitment to on-going improvements in the home. Systems are in place to enhance communications with relatives for example meetings, comment cards and individual reviews of care pertaining to residents’ The home provides excellent activity provision. An activities co-ordinator employed five days per week. Activity provision is interesting and varied ranging from basic numeracy and literacy work to computer skills, gardening, art and craft work, day trips and outings. Activities are well attended and are very much enjoyed by the residents’. Ashbourne Residential Home DS0000024969.V257232.R01.S.doc Version 5.0 Page 6 Generally Ashbourne is well maintained in respect of décor and furnishings. It offers a number of lounges to enable residents’ to be with their families in private during visiting times or for them to have time alone if they want to. The home actively encourages residents’ to maintain contact with family and friends. Visiting times are open and flexible. One resident said, “ My wife visits me every afternoon”. Residents’ commented positively about the home. One said, “ I am as happy as anyone in a care home could be. I love each and everyone, of the staff. I like the place and have made new friends”. Another commented “ I have no complaints, none what so ever”. Another resident said “ I will always be grateful to this lot for the way they have looked after me”. Staff in all roles observed during the inspection appeared hard working, caring and friendly. The staff all appear to have a good knowledge of each residents situation and needs. The atmosphere of the home is warm, welcoming and friendly. What has improved since the last inspection? Since the last inspection an admin person has been appointed to relieve the manager of some administration tasks. Re-decoration has been carried out in lounges, new chairs have been purchased. A number of bedrooms have also been redecorated. Factions and conflict within in the staff team have been and are still being addressed. Relationships do appear to have improved. The home has improved in all areas of record keeping. The manager and staff team have put a lot of energy into improving and maintaining care plans and other records. It is evident that staff, at all levels, are gaining confidence in using and completing the homes records and documentation. Ashbourne Residential Home DS0000024969.V257232.R01.S.doc Version 5.0 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ashbourne Residential Home DS0000024969.V257232.R01.S.doc Version 5.0 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 Ashbourne Residential Home DS0000024969.V257232.R01.S.doc Version 5.0 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): 2. More attention is needed to ensure that all residents’ are issued with an agreed terms and conditions/ contract which contains current information to the required level. EVIDENCE: Although a terms and conditions document is in operation in the home a number of these seen referred to the National Care Standards Commission instead of The Commission for Social Care Inspection, they did not detail a current fee and had not been signed or dated by the resident or their representative. Ashbourne Residential Home DS0000024969.V257232.R01.S.doc Version 5.0 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): 9,10. Fine tuning is required to ensure that medication systems are robust and are followed diligently to prevent any risks to residents. Generally residents’ feel they are treated with respect. EVIDENCE: The morning medication administration was briefly observed. Good practice was observed in that the senior stayed with each resident to make sure that they had taken their medication. The medication trolley was locked when she had to move away from it. Medication tots and drinks were made available before the medication round commenced. Generally topical preparations are date labelled when opened. Two new medication trolleys have been obtained ready for use. There was evidence available to demonstrate that the manager is making plans to ensure that all staff responsible for medications receive accredited medication training. It was observed that the senior was signing the medication record before residents’ had been given their medication. There was a gap of five days where Ashbourne Residential Home DS0000024969.V257232.R01.S.doc Version 5.0 Page 11 one resident had not had one of their medications because there was no stock available. Prescribed creams are not always entered on the medication records. Records revealed that the preferred name for each resident is determined and recorded on their file. A payphone is available for residents’ to make private phone calls. It was observed that toilet and bathroom doors are kept closed when in use. Staff knock residents’ doors before entering. Staff were heard giving residents’ choices in respect of food and activities. Residents’ responded positively to staff indicating good relationships. There were locks on toilet and bathroom doors however, it is questionable if all residents’ would be able to use these. One resident commented “ The staff are very good they treat me as an individual”. Ashbourne Residential Home DS0000024969.V257232.R01.S.doc Version 5.0 Page 12 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): 14,15 The home actively involves residents’ to maintain contact with family and friends. Generally, residents’ receive a wholesome appealing diet in pleasing surroundings. Further developments are needed in respect of menus. EVIDENCE: The home has advocacy information on display. All residents’ bedrooms viewed held a range of personal effects. Some had numerous personal belongings including televisions, audio equipment, pictures and ornaments. Inventories are in operation to record any personal belongings. The home has a four weekly menu cycle. The menus only detail breakfast, lunch and tea not supper. Whilst it is positive that food consumption charts are in operation, supper offered/ taken is not being recorded. Mealtimes, breakfast and lunch were partially observed. There was no specific staff in attendance during breakfast. Two residents’ were seen eating porridge. They clearly enjoyed this but the porridge was going down the front of their clothing. No serviettes or other protection had been offered. The breakfast looked appealing. Residents’ could choose from a range of cereals and or toast. A number selected a hot option which was attractively served and consisted of toast, egg and tomatoes. Ashbourne Residential Home DS0000024969.V257232.R01.S.doc Version 5.0 Page 13 The main meal consisted of chicken nuggets or scampi chips and beans. During this meal staff were available to give assistance and serviettes were offered. The dining room is a large room which is decorated to a good standard. The pictures on the wall and the wall unit make the dining room feel ‘homely’. Music was playing in the background but not too loud. Tables were nicely laid, flower arrangements giving a nice touch. Ashbourne Residential Home DS0000024969.V257232.R01.S.doc Version 5.0 Page 14 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): 16,18 Residents and their relatives can be confident that their complaints will be listened to and acted upon. Further developments are needed to ensure that residents’ are protected from abuse at all times. EVIDENCE: The home has a complaints procedure who has been produced in standard print only and may not be appropriate to all. The complaints procedure is on display within the home. The manager confirmed that during meetings and individual resident reviews she reminds residents’ and relatives of the homes complaints’ procedures and how these can be accessed. One resident has twice in the last year approached the home and Commission about a situation he is dissatisfied about. This does not however, involve staff. This resident was spoken to during the inspection. The home since the last inspection has been ‘taken over ‘ by another large organisation. The manager at the present time is not familiar with this organisations abuse reporting procedures, they could not be located during the inspection. The home has in the past been pro-active in addressing concerns involving staff. Unfortunately one staff member has been disciplined and a provisional referral has been made to the Protection Of Vulnerable Adult list. This staff member no longer works at the home. A new whistle blowing policy was available to peruse. Staff have received recent adult abuse awareness training. Ashbourne Residential Home DS0000024969.V257232.R01.S.doc Version 5.0 Page 15 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): 19,26 Generally the home is maintained to a satisfactory standard. Further improvements are needed in respect of toilet, bathroom and laundry décor. The home is dust free and clean. EVIDENCE: The home overall is maintained to a satisfactory standard. A handyperson is employed full time to ensure that general maintenance is addressed on an ongoing basis. The organisation provides decorators to attend to large decorating tasks. However, a number of bedrooms were seen to require decorating work, along with window frames and sills. Many toilets and bathrooms need redecoration and the sealant replaced at the edges of the floors this also applies to the staff toilet. The garden is very overgrown in places and needs a good tidy before winter sets in. The patio area is maintained. A number of staff and residents’ were seen sitting outside during the afternoon. Since the last inspection a number of lounges have been re-decorated and provided with new easy chairs. New easy chairs and curtains have been provided in the reception area. Ashbourne Residential Home DS0000024969.V257232.R01.S.doc Version 5.0 Page 16 Concern was highlighted about the noise in the home emanating from the homes door alarms and the homes call system. The noise at times was considerable. Generally the home was seen to be kept to a good level of cleanliness. Toilets and bathrooms are provided with liquid soap, paper towels and waste bins. Signs to remind people to wash their hands were displayed in bathrooms and toilets viewed. The inset lights in the dining room had a number of dead insects collected. The laundry was identified as the most cause for concern as it is of a small size for the washing demands of the residents’. The laundry floor was not intact in all areas. The sink had a covering of lime scale. The home at the present time does not use red disposable bags to reduce the handling of soiled clothes. The laundry is equipped with two commercial washing machines and two dryers. It is positive that dedicated laundry and domestic staff are provided daily. Ashbourne Residential Home DS0000024969.V257232.R01.S.doc Version 5.0 Page 17 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 Staffing levels provided on the am shift are inadequate. Other times they appear satisfactory. EVIDENCE: Staffing levels are provided as follows; Am one senior and three care staff (Plus the manager during the week) Pm One senior and two care staff. Nights One senior and two carers. Domestic, laundry and catering staff are provided every day. A handyperson and activities co-ordinator work Monday to Friday. The shortfall identified was the apparent inadequate staffing numbers during the early morning particularly at breakfast time. The senior was administrating medications which left three staff to attend to personal care needs. There were no staff available to supervise or give assistance in the dining room. Residents’ commented positively about the staff indicating that they are friendly and caring. One resident said, “ I love each and everyone of them”. Ashbourne Residential Home DS0000024969.V257232.R01.S.doc Version 5.0 Page 18 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): 31,33,35,38 The Commission has approved the manager as being a fit person to run the home. The manager has yet to attain the required qualifications. Further development is required to ensure that the home is run in the best interests of the residents’ Generally staff are appropriately supervised. Generally health and safety is observed within the home. EVIDENCE: The manager has been in post for a number of years. She has considerable experience of caring for older people in care home and other environments. The manager is keen to up date her knowledge and skills. She has recently attained a health and safety certificate. The manager to date has not attained the required N.V.Q award. Although she has recently enrolled onto a course the funding has not been made available. Ashbourne Residential Home DS0000024969.V257232.R01.S.doc Version 5.0 Page 19 The home has robust monitoring processes in operation in relation to all aspects of the home. The organisation requires that a number of monitoring processes be undertaken each month. Comment cards are made available in the front entrance hall. Resident and relative meetings are held regularly. The home has yet to initiate a process of gaining resident and other stakeholder views. A development plan and business plan for this financial year have yet to be produced. One resident spoken to very much controls his own finances. Other residents have certain amounts of money held in safekeeping by the home. Two residents’ money held was checked. The balance identified correct against money held. There was evidence available to demonstrate that a personal inventory for each residents’ belongings is available and maintained. Evidence was available to demonstrate that staff receive regular one to one supervision. The manager confirmed that in addition to formal processes staff are taught new skills, an example being record keeping on a one to one basis and are supported at all times to reach their full potential. Health and safety, maintenance and service records were randomly assessed and appeared to be in good order with the exception of the Oxford Mermaid hoist which needs attention. Generally staff training is up to date or has been booked. West Midlands Fire Service are carrying out an inspection in the near future. Ashbourne Residential Home DS0000024969.V257232.R01.S.doc Version 5.0 Page 20 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 2 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 x x x x x x 2 STAFFING Standard No Score 27 2 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 3 x 3 Ashbourne Residential Home DS0000024969.V257232.R01.S.doc Version 5.0 Page 21 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 OP1 Regulation 5(1)(b) Requirement Timescale for action 06/12/05 2 OP8 12(1)(a) The registered person and manager must ensure that each resident is issued with an agreed terms and conditions/ contract depending if they are funded by a Local Authority or are selffunding. The terms and conditions document must make reference to the CSCI not NCSC, detailed the current fee applicable for each resident and be signed and dated. The registered manager must 21/10/05 ensure that all care delivery records are maintained at all times. This to include daily food / fluid intake records in respect of each resident. ( Timescale of 21/04/05 not fully met). The registered provider must ensure that the personal care records (for example oral care), are maintained and up to date at all times. (Timescales of 05.02.05 and 21/04/05 not fully met.) 3 OP8 12(1)(a) 11/10/05 Ashbourne Residential Home DS0000024969.V257232.R01.S.doc Version 5.0 Page 22 4 OP9 13(2) 5 OP9 13(2) 6 OP9 13(2) 7 OP9 13(2) 8 OP9 13(2) 9 OP9 13(2) 10 OP9 13(2) 11 OP9 13(2) The registered manager must continue with plans to ensure that all staff responsible for medications receive accredited medication training to ensure that all staff receive this training by the timescale applied. The registered person and manager must ensure that all residents who self medicate are provided with a lockable facility. Where residents’ refuse this facility a risk assessment must be carried out. The registered person and manager must ensure that staff do not sign medication records until they are sure that the resident has taken their medication. The registered person and manager must ensure that sufficient medication is available at all times to ensure that residents’ are given their medications as prescribed. The registered person and manager must ensure that an approved medication book (e.g. BNF) is available at all times. The registered person and manager must ensure that where medication records are handwritten the information is verified as correct by two staff. The registered person and manager must ensure that all prescribed topical preparations are signed for on the medication administration records when applied. The registered person and manager must ensure that an example staff signature/ initial list is produce in respect of all staff who have a responsibility for medications/ medication administration. DS0000024969.V257232.R01.S.doc 01/12/05 01/11/05 11/10/05 11/10/05 11/11/05 11/10/05 11/10/05 01/11/05 Ashbourne Residential Home Version 5.0 Page 23 12 OP15 12(3) The registered person and manager must ensure; That staff are available to give assistance to those residents’ who require help at every mealtime. That serviettes or appropriate protective clothing is provided to residents who need this every meal time. The registered person and manager must ensure that; The homes menus detail four main meals per day breakfast, lunch, tea and supper. That food consumption charts reflect four meals offered per day. 18/10/05 13 OP15 17(2) Schedule 4(13) 08/11/05 14 OP10 12(4)(a) 15 OP16 22(2) 16 OP18 13(6) The registered person and manager must ensure that easy to use, safe, suitable locks are provided on all toilet and bathroom doors. The registered person and manager must ensure that the complaints procedure is produced in a format appropriate to all residents’. The registered person and manager must ensure that all staff are familiar with their new organisations policies and procedures in respect of adult protection. 01/12/05 01/12/05 01/11/05 17 OP19 13(4)( c) All staff must read, sign and date the said policies and procedures. The registered person and 01/11/05 manager must ensure that the noise levels from door alarms and call systems is considerable reduced. DS0000024969.V257232.R01.S.doc Version 5.0 Page 24 Ashbourne Residential Home 18 OP19 23(2)(b) ( c)(d) An action plan must be provided to the CSCI dealing how and when this requirement will be met. The registered provider must inform the lead inspector based at the CSCI office of its intentions regarding the finishing of the redecoration programme. (Timescale of 20/05/05 not fully met). This to include the following; Corridors Bedrooms ( That have not yet been redecorated) Stair wells. Toilets and bathrooms( including the staff toilet). The replacement of sealant at the edges of toilet and bathrooms floors. 20/11/05 19 OP19 23(2)(c ) 20 21 OP19 OP26 23(2)(b) 23(2)(d) 22 OP26 23(2)(j) The registered person and manager must ensure that the corridor carpets both ground and first floors are replaced. The registered person must ensure that the garden is tidied before the winter sets in. The registered person and manager must ensure that the inset lights in the dining room are cleaned regularly. The registered provider must inform the CSCI of its intentions in respect of the laundry extension. ( Timescale of 01/05/05 not fully met as no firm plans have been made). The registered person and manager must ensure that; DS0000024969.V257232.R01.S.doc 01/12/05 01/12/05 01/11/05 20/11/05 23 OP26 23(2)(b) 23(2)(d) 01/12/05 Ashbourne Residential Home Version 5.0 Page 25 The laundry floor is replaced. The sink is the laundry is cleaned regularly and is free from lime scale. The registered manager must 21/11/05 ensure that the carpets in the bedrooms identified during the inspection as having an odour are replaced. If the odour persists then other measures must be taken to manage and eradicate the odour. ( Timescale of 21/05/05 not met). The registered person and manager must increase staff during the early morning by one. The registered person must inform the CSCI when the manager will commence the required N.V.Q training. An immediate requirement was issued in respect of this issue. The registered person and manager must instigate a process to determine resident, relatives and other stakeholders views of the services provided by the home. The registered person and manager must produce a business plan pertaining to the financial years 2005/2006. The registered provider and manager must ensure that a foundation programme be developed and implemented to the prescribed standard. 24 OP26 16(2)(k) 25 26 OP27 OP31 18(1)(a) 9(1)(i) 01/11/05 21/10/05 27 OP33 24 01/12/05 28 OP33 24 01/12/05 29 OP30 18(1)(a) 01/12/05 30 OP38 13(4) (Timescale of 01.03.05 and 01/06/05 not met). The registered provider and 20/11/05 manager must ensure that a qualified person carries out a risk DS0000024969.V257232.R01.S.doc Version 5.0 Page 26 Ashbourne Residential Home assessment of the premises (Timescale of 05.02.05 not fully met.) There was evidence available to demonstrate that this has been partially met. The registered person and manager must ensure as a matter that the Oxford Mermaid Hoist receives the required attention. 31 OP38 13(4) 01/11/05 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 Residential Home DS0000024969.V257232.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Ashbourne Residential Home DS0000024969.V257232.R01.S.doc Version 5.0 Page 28 - 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!