Inspection on 14/09/06 for Ashbridge Lodge

This inspection was carried out on 14th September 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashbridge Lodge 19/11/07

Ashbridge Lodge 10/05/06

Ashbridge Lodge 22/09/05

Ashbridge Lodge 19/05/05

Ashbridge Lodge 31/03/05

Ashbridge Lodge 18/08/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Ashbridge Lodge 5 Ashbridge Road Leytonstone London E11 1NH Lead Inspector Sandra Jacobs-Walls Unannounced Inspection 14th September 2006 10:30 Ashbridge Lodge DS0000007276.V311885.R01.S.doc Version 5.2 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 Ashbridge Lodge DS0000007276.V311885.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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. Ashbridge Lodge DS0000007276.V311885.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashbridge Lodge Address 5 Ashbridge Road Leytonstone London E11 1NH 020 8989 7767 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) Mr Siddicq Yadallee Millicent Marjorie Tracey-Adejimola Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Ashbridge Lodge DS0000007276.V311885.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home can provide care for one named service user with a mental health needs. 10th May 2006 Date of last inspection Brief Description of the Service: Ashbridge Lodge is a residential home for five persons (currently 3 women and 2 men) with learning disabilities. Four of the residents, whose ages range from 32 to 63 years, have lived there for 9 years. The most recent resident was admitted in February 2004. Residents have a pet cat. The house is located in a residential area of Leytonstone within the London Borough of Waltham Forest. The home is situated close to local amenities; a post office and mini convenience store are a road away and other facilities, which include places of worship, public transport, leisure centre, public library, shopping centre and restaurants are within walking distance for staff although too far for most of the residents to manage. All service users have their own bedrooms; two of which are on the ground floor. There is no lift. Three of the rooms have en suite toilets; the other two have wash hand basins in the room. There is a communal lounge/diner, a kitchen and a good size back garden accessible by steps. The office is on the first floor. At the time of the inspection, the registered manager was on extended leave and as per a prior arrangement with CSCI, a new registered manager, (the home’s former deputy manager) is now in place. Ashbridge Lodge DS0000007276.V311885.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection of Ashbridge Lodge took place on September 14th 2006 for the duration of four hours. The purpose of the inspection was to assess the service against key National Minimum Standards and to gauge the home’s success at addressing outstanding requirements made at the last inspection that was conducted in May 2006. Present throughout the inspection was the newly appointed registered manager. The inspection process included the review of two service users’ files in detail, discussion with three service users, a tour of the home’s premises, the review of the personnel file of one member of staff and the review of other key documentation. The inspector would like to thank all service users and the registered manager who co-operated and contributed to the inspection. As a result of the inspection findings, three requirements and no recommendations were made. What the service does well: The inspector was impressed by the significant improvement in the quality of services offered by the home in comparison to that observed at the previous inspection. Service users needs are well known to staff since all service users had lived at the home for a significant period of time. The home meets well the identified needs of service users and documentation reviewed on service users files were recorded well. Three service users spoke briefly to the inspector upon arrival at the home and indicated that they were very satisfied with services provided and were happy with the new management structure. Service users appreciate the efforts of the staff team and the home’s environment is homely and comfortable. Ashbridge Lodge DS0000007276.V311885.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: As previously mentioned in this report, the home had successfully addressed the vast majority of outstanding requirements made at the last inspection. Noted during this inspection for improvement is the need for an access ramp to be installed at the rear entry to the building, the repair of a broken lock to the downstairs toilet and for all significant events as outlined in the Care Homes Regulations to be reported to CSCI. Ashbridge Lodge DS0000007276.V311885.R01.S.doc Version 5.2 Page 7 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. Ashbridge Lodge DS0000007276.V311885.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashbridge Lodge DS0000007276.V311885.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 Quality in this outcome area is good. This judgment had been made using available evidence including a visit to this service. EVIDENCE: No new service users had been admitted to the home since the last inspection therefore standards relating to prospective service users could not be accessed. However, the previous inspection had highlighted the need for revision to be made to the home’s Statement of Purpose and for the Service User Guide to be made available on site. The inspector reviewed the newly revised Statement of Purpose document and was satisfied that it contained all information as specified in Schedule 1 of the Care Homes Regulations. The service user Guide, which had not been made available at the last inspection, was also reviewed. The inspector was satisfied that that this document was appropriately written in language accessible to service users and also contained all required information. Ashbridge Lodge DS0000007276.V311885.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is good. This judgment had been made using available evidence including a visit to this service. EVIDENCE: Service users who spoke with the inspector indicated that they felt the service was meeting their needs well. The inspector noted that the assessment and care planning tool used by staff had been changed to included more comprehensive information about service users needs and how these would be met by either the home or other involved professionals. The registered manager commented that all service users had recently participated in updated assessment of need and commented that review of identified needs would occur systematically or as prompted by service users’ changing circumstances. The previous inspection had highlighted the need for staff to be more proactive in involving service users in the decision making process and also for files to demonstrate this process. The inspector noted on the two service user files reviewed that documentation had more keenly evidenced staff prompting service users to make decisions for themselves. The daily recording section of service user files for example, contained good information about service users Ashbridge Lodge DS0000007276.V311885.R01.S.doc Version 5.2 Page 11 deciding not to attend local day centres, not to participate in group activities or deciding for themselves whether the wished to attend to personal care tasks. The inspector also noted that the format of the home’s monthly residents meeting had changed so that issues presented by service users were given priority as opposed to the issues brought to the meeting by staff. Additionally, a new recording book had been established that highlighted significant events in that indicated service users making choices or decisions that were outside the norm of their usual preferences. The inspector felt this was an effective system to prompt staff to demonstrate and record choices and decisions of service users, but that this process should be encouraged to become part of routine recording in service users files and not specifically in an assigned log. With regard to risk taking, the inspector was satisfied that all service user files contained updated risk assessments and that these related specifically to individual service users. So for example, risk assessments were seen that addressed the risk posed to one service user who was prone to falling due to unsteadiness on her feet. Another service user had been diagnosed as being epileptic and his risk assessment addressed risks posed as a result of his medical condition. For another service user, risk assessments were in place to address risks posed due to him smoking in his bedroom. The inspector was satisfied that risk assessments both identified the risk posed and offered guidance as to how these risks could be minimised and/or eliminated. Ashbridge Lodge DS0000007276.V311885.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17 Quality in this outcome area is good. This judgment had been made using available evidence including a visit to this service. EVIDENCE: It was the inspector’s view that the since the last inspection the lifestyle of service users living at Ashbridge Lodge had improved significantly. Previously the inspector had been concerned that few new activities or experiences had been offered to service users and so their capacity for self-development and the opportunity to experience meaningful activities had been limited. The registered manager informed the inspector of the attempts of the service to offer more meaningful activities and a differing range of experiences to enhance the lifestyle of service users. An activities log had been created that highlighted activities available to service user to consider. The home now had unlimited access to a vehicle owned by the organisation on the day that few service users attended day centre faculties. This had not been the case previously and the access to the van had resulted in more creative activities being made available to service users. So for example, service users had the opportunity to attend day trips to the seaside and go on holiday. Shopping trips were now more regularly offered as were trips to eat out, go swimming Ashbridge Lodge DS0000007276.V311885.R01.S.doc Version 5.2 Page 13 and bowling etc. The service had increased the home’s staffing levels from two staff members to three to facilitate taking service users out when they were not attending day centres. The registered manager commented however, that while new opportunities had been developed, staff were still working hard to encourage service users to participate as most appeared content to continue to participate in home based recreational activities such as watching television and videos, playing music, colouring and cutting pictures out of magazines, a habitual past time of one service user in particular. The registered manager said that staff continued to respect service users wishes, but similarly continued to encourage their participation in alternative activities. Service users were equally encouraged to participate in community activities and frequently would be encouraged to assist complete shopping for food and clothes go for walks in the local park, attend church and local community resources that met service users’ particular religious and cultural needs. Service users were also encouraged to attend the cinema and attend picnics locally. The registered manager informed the inspector that most service users (with the exception of one, who had limited contact with family) enjoyed a good relationship with their family members, some of whom visited at Ashbridge Lodge or would invite service users to stay with them overnight or several days to attend family celebrations. The home also hosted barbeques and birthday parties for service users that friends and family members are invited to attend. Service users were encouraged to develop and maintain friendships external to the homes, in particular via attendance at local day centres. Service users who spoke with the inspector indicated that they enjoyed meals offered by the home. The inspector reviewed a number of weekly menu plans that indicated that meals offered were varied, nutritiously balanced and were in accordance to service user preferences. One service user’s file indicated that she had a particular liking for traditional English meals, which were offered. The registered manager commented and menu plans evidenced that for the two women who were West Indian/Caribbean in origin, their dietary preferences were also catered for by the home. Ashbridge Lodge DS0000007276.V311885.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 &20 Quality in this outcome area is good. This judgment had been made using available evidence including a visit to this service. EVIDENCE: The registered manager commented that service users largely completed personal care tasks independently of staff, in most cases, staff were available to monitor and prompt personal care tasks. Care plans seen were explicit in detailing the level of independence of service users and made a fair attempt to outline service users preferences and wishes. So for example, one service user file outlined the service users’ habitual reluctance to bathe or shower. Staff were advised to encourage the service user to shower regularly but to respect any refusal of the service user to do so. Another service user needed to apply regularly dermatological cream to her body; staff prompted and on some occasions applied the prescribed medication themselves with the service user’s permission. Another service user file reviewed detailed staff’s efforts to prompt the service user have her hair groomed, despite considerable reluctance. Staff sensitively addressed the issue and managed to defuse the amounting distress of the service user. Service user files reviewed by the inspector contained very comprehensive information about the physical and emotional health needs of service users. All service users were registered with GP’s of their choice and were Ashbridge Lodge DS0000007276.V311885.R01.S.doc Version 5.2 Page 15 appropriately referred/accessed services via other health professionals such as physiotherapists, chiropodists, consultant psychiatrist etc. Health appointments and their outcomes were also well documented. The inspector reviewed the home’s documentation of accidents and was satisfied that these were appropriately recorded and managed. The service will need to ensure however, that all significant incidents, such as accidents and subsequent hospital admissions are reported to CSCI as required. The inspector observed that service user medication was kept securely locked in a medication cabinet in the kitchen. The medication information for one service user was reviewed in detail. Medication information documented on file was clear and the completion of Medication Action Records (MAR) was accurate and consistent with the home’s medication policies. Clear information was evident about the responsibility of administering the service users medication when he attended a work programme. The registered manager informed the inspector that no staff member was permitted to administer service user medication without first completing medication training and undergoing a thorough assessment of their competency in this area of their work. This was supported by information seen in the personnel files of a newly recruited member of staff of an assessment of her skills following medication training. Ashbridge Lodge DS0000007276.V311885.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgment had been made using available evidence including a visit to this service. EVIDENCE: The previous inspection had highlighted the need for the home to revise its complaints procedure to outline the responsibility and management of any complaint made against the home’s registered manager. The inspector reviewed the revised complaints procedure and was satisfied that the omitted information was now included. The home’s complaints log was also reviewed, one complaint had been made since the last inspection and this related to service user’s requesting the home’s heating be put on, on one occasion during the summer. The inspector was satisfied that the issue had been managed and documented appropriately. Service users who spoke with the inspector indicated that they had no complaints to make about the home, the inspector noted that opportunity to do so was explored in monthly residents’ meetings or individually with key workers. The previous inspection had raised concerns about staff’s knowledge and access to information regarding the home’s adult protection procedures. These policies were in need of amendment to ensure practice was in accordance with local authority adult protection protocols. Since the last inspection the registered manager had obtained the written adult protection guidelines of the local authority and had made this available to staff. In addition, all staff had received training in adult protection via an external training body. Adult protection issues are also discussed as part of the induction process for new staff and as an ongoing issue for the staff group generally. No allegation of abuse or suspicion of abuse had occurred in the home since the last inspection, Ashbridge Lodge DS0000007276.V311885.R01.S.doc Version 5.2 Page 17 there are good procedures and practices in place to ensure the prevention of financial abuse of service users. Ashbridge Lodge DS0000007276.V311885.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27 & 30 Quality in this outcome area is good. This judgment had been made using available evidence including a visit to this service. EVIDENCE: The previous inspection had highlighted a number of issues in relation to the home’s environment. In particular, an occupational therapist assessment had recommended an extension to the ground floor shower, two service user bedroom windows needed to be replaced, an access ramp to both the front and rear entry to the building needed to be in place, garden furniture needed to be purchased and stained carpets in one service user bedroom needed to be replaced. The inspector was encouraged to observe that all highlighted environmental issues (with the exception of the access ramp required to the rear of the building, which had been delayed), had been successfully addressed. The inspector participated in a tour of the home’s premises to confirm the home’s improvement to its environment. The service will need to repair a broken lock to the downstairs toilet to ensure the dignity of service users and staff when in use. On the day of the unannounced inspection, the home was impeccably clean and hygienically maintained.. Ashbridge Lodge DS0000007276.V311885.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33 34 & 35 Quality in this outcome area is good. This judgment had been made using available evidence including a visit to this service. EVIDENCE: The staff group, with the exception of one newly recruited staff member had been working at the home for a significant period of time and were well known to service users. Those service users who spoke with the inspector made positive comments about the staff group. The inspector was satisfied that sufficient staff were employed to meet the aims and objectives of the service and noted that an additional staff member was routinely on shift on the day that few service users attended day centre facilities; this was to ensure that there was sufficient staff to facilitate trips out. The home’s staffing rota was reviewed and documented information confirmed the increase in staff cover. The registered manager commented and provided documented evidence to confirm ongoing training opportunities that were available to staff to enhance skills and knowledge. Since the last inspection staff had participated in a range of training, including adult protection, manual handling, managing aggression, health and safety, first aid and fire safety. The organisation had identified an independent training body that was in the process of offering relevant training opportunities to staff that met the specifications of Skills for Care as equired. In addition, all staff members had completed or were in the process of completing NVQ awards at level 2 or 3; the most recently recruited staff member was negotiating enrolment on NVQ training. The registered Ashbridge Lodge DS0000007276.V311885.R01.S.doc Version 5.2 Page 20 manager continues to complete her NVQ training at level 4. Training focused on learning disability and mental health issues had been arranged for staff to participate later in the autumn. The inspector reviewed the personnel file for one member of staff and was satisfied that full staff information as outlined in the regulations was evidenced and that the recruitment of the staff member had been conducted in accordance with the service’s selection and recruitment policies. An induction process had been completed and ongoing monitoring of the staff member’s performance and training opportunities were well documented. As required as a result of the last inspection, the home’s job application form has been amended to facilitate comprehensive information regarding the employment histories of applicants. The registered manager produced evidence of a staff supervision agreement that she had developed to better co-ordinate the individual support of staff members. A supervision schedule was also in place and documented evidence seen by the inspector, confirmed that staff received regular and comprehensive individual supervision. This was marked improvement to the level of support evidenced at the previous inspection. The service is commended for the attention paid to the support and development of the staff group via training and supervision. This was clearly to the benefit of service users and the overall quality of care provided by the home. Ashbridge Lodge DS0000007276.V311885.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38, 39, 42 & 43 Quality in this outcome area is good. This judgment had been made using available evidence including a visit to this service. EVIDENCE: As required, a registered manager (the home’s former deputy manager) was in place during the interim of the maternity leave of the previous post holder. It was the inspector’s view that the consequence of the new staffing structure and enthusiasm of the new registered manager and the seemingly positive working relationship with the proprietor had resulted in numerous positive developments to the service and ultimately good outcomes for service users. The home was very well run in comparison to previous indication. The registered manager’s keen eye for detail, ‘hands on’ approach to care and strong leadership skills has had a significant impact on the quality of service. The registered manager had developed internal strategies to review the performance of the service; this in conjunction with the proprietor’s monthlyunannounced monitoring visits (which were evidenced) had contributed to significant service improvement. The inspection had highlighted some very good systems and practice developments that have enhanced positive Ashbridge Lodge DS0000007276.V311885.R01.S.doc Version 5.2 Page 22 outcomes for service users; it is the inspector’s expectation and indeed that of the Commission that the service’s evidenced quality of care be maintained from this point onwards. Ashbridge Lodge DS0000007276.V311885.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 3 3 X 3 3 3 Ashbridge Lodge DS0000007276.V311885.R01.S.doc Version 5.2 Page 24 Yes Are there any outstanding requirements from the last inspection? 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 YA19 Regulation 37 Requirement The registered manager must ensure that all service user accidents and subsequent hospital admissions are reported to CSCI The registered manager must ensure that the broken lock in the downstairs toilet is repaired The registered person must ensure that an access ramp is placed at rear of the home’s premises. Timescale for action 31/10/06 2. 14. YA27 YA29 23(2)(c) 23(2)(n) 31/10/06 31/10/06 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 Ashbridge Lodge DS0000007276.V311885.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ 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 Ashbridge Lodge DS0000007276.V311885.R01.S.doc Version 5.2 Page 26 - 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!