Inspection on 22/02/06 for Ashgale House

This inspection was carried out on 22nd February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 39 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashgale House 03/11/08

Ashgale House 15/10/07

Ashgale House 21/06/07

Ashgale House 19/12/06

Ashgale House 20/04/06

Ashgale House 23/11/05

Ashgale House 02/11/04

Ashgale House 04/05/04

Ashgale House 26/02/04

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 Ashgale House 39-41 Hindes Road Harrow Middlesex HA1 1SQ Lead Inspector Ms Sue Barker Unannounced Inspection 22nd February 2006 08:45 Ashgale House DS0000017514.V270890.R01.S.doc Version 5.1 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 Ashgale House DS0000017514.V270890.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 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. Ashgale House DS0000017514.V270890.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ashgale House Address 39-41 Hindes Road Harrow Middlesex HA1 1SQ 020 8863 8356 020 8863 8491 ashgalehouse@aol.com 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 Aslam Dahya Mr Siyoum Beyene Care Home 14 Category(ies) of Learning disability (13), Learning disability over registration, with number 65 years of age (1) of places Ashgale House DS0000017514.V270890.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Within this Fourteen, 4 People may be residents with additional Physical disability. People with Physical Disability will reside on the ground floor of the building. Temporary variation agreed for one named individual (MB) aged 66 years for the duration of her stay. 23rd November 2005 Date of last inspection Brief Description of the Service: Ashgale House is a registered care home providing personal care and accommodation for a maximum of 14 adults aged 18-65 who have learning disabilities. The building is divided into 2 units, with the home registered to provide 8 places on the ground floor (four of these places may be occupied by service users who additionally have physical disabilities) and 6 places on the first floor. Within the 6 registered places in the first floor unit, 2 places are made available to residents (on a local authority contract basis) as respite. The Registered Provider is Allied Care, the Responsible Individual being Mr. Aslam Dahya. The Registered Manager is Mr. Siyoum Beyene. The home is located in a busy residential road on the outskirts of central Harrow, close to shops, leisure and other community amenities. The home was registered in May 2001 and is a two storey building All the home’s bedrooms are single, and none have en-suite facilities. The home has a large garden to the rear that is accessed through the ground floor unit. Ashgale House DS0000017514.V270890.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was conducted by Mrs Sue Barker and Ms Judith Brindle (Regulation Inspector). The unannounced inspection commenced at 8.45am and ended at 5.25pm. The Inspectors were pleased to greet or speak with most residents living in the ground floor unit; this is in addition top observing the pattern of life in Ashgale House. Most residents went out to day placements. Some residents spoke positively about the care, support and food that they eat in Ashgale House. Four residents let the Inspectors know how they spend their time in Ashgale House. One resident spoke about their experiences at day placement. The Inspectors were pleased to meet with some visitors to the care home who were visiting a resident. The unannounced inspection also involved touring the building, viewing some of the statutory recording and speaking with staff, Mr Beyene (Registered Manager) and Ms Elliot (Deputy Manager). The management and staff at Ashgale House were most helpful and facilitated the unannounced inspection processes fully. The Inspectors were made most welcome and would wish to thank those in Ashgale House for the hospitality received. What the service does well: There is a Statement Of Purpose for prospective residents and their representatives in order to make an informed choice about where to live. The assessment of prospective residents to Ashgale House presents as thorough. Care plans are being developed for and with residents, in order to ensure a consistency of their care and support. This work must be continued. Risk assessments are being developed for residents, as part of the care home’s risk management culture. Residents are offered food from the care home’s menus. One resident confirmed that they could choose what they want to eat. Some residents indicated that they enjoy their meals in Ashgale House. Residents’ needs are being met by a staff team in Ashgale House that is appropriately trained. Residents benefit from living in a care home that has a Registered Manager, who has the required experience that is updated with training. Resident’s views on the operation of the care home, and those of their relatives and stakeholders, are sought as part of the care home quality monitoring strategy. The health, safety and welfare of residents in Ashgale House are largely protected in Ashgale House. Ashgale House DS0000017514.V270890.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? 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. Ashgale House DS0000017514.V270890.R01.S.doc Version 5.1 Page 7 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 Ashgale House DS0000017514.V270890.R01.S.doc Version 5.1 Page 8 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&2 There is a Statement Of Purpose for prospective residents and their representatives to make an informed choice about where to live. This requires some amendment to include all aspects of the service in Ashgale House. The assessment of prospective residents presents as thorough. EVIDENCE: The Statement Of Purpose for Ashgale House was displayed in the care home. This presented as comprehensive, though did not include reference to the ‘respite care’ aspect of the service in its contents. This must be included with an updated version of the Statement Of Purpose forwarded to the Commission for Social Care Inspection. The Inspectors discussed the assessment of potential residents with Ms Elliott and Mr Beyene, who undertake the assessments in Ashgale House. Examples of such recent assessments were viewed that presented as comprehensive. Mr Beyene stated that the care home would be requesting copies of the single Care Management (health and social services) assessments, in respect of potential residents, from referring authorities. The Inspectors noted and acknowledged that staff had done much work on residents’ care plans since the last unannounced inspection. This is referred to in Standard 6 The process of assessment includes consideration of any challenges that the potential resident may present to the care home. The Inspector viewed some guidance and strategies for staff in respect of how to work with residents who Ashgale House DS0000017514.V270890.R01.S.doc Version 5.1 Page 9 may potentially challenge the service at Ashgale House. Ms Elliot that the care home’s strategies are based upon distraction etc rather than physical restraint. Ashgale House DS0000017514.V270890.R01.S.doc Version 5.1 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&9 Care plans are being developed for and with residents, in order to ensure a consistency of their care and support. This work must be continued. Risk assessments are being developed for residents, as part of the care home’s risk management culture. EVIDENCE: The Inspectors viewed examples of residents’ care plans that were in the process of being fully developed for all residents. The Inspectors acknowledged that staff had done a lot of work on the new care plans. Newer care plans included individualised information about residents’ health, personal and social care needs, with clear goals. There were individualised guidelines for staff on residents’ medical conditions and in respect of working with residents who may challenge the service in Ashgale House. This work must be continued in respect of all the residents living in Ashgale House. There is evidence of the involvement of residents in the development of their care plans. There was evidence of reviews of care plans having taken place, this must be continued with a record maintained of outcomes and decisions made. Ashgale House DS0000017514.V270890.R01.S.doc Version 5.1 Page 11 Care plan documentation etc is available to residents in their bedrooms. Care must; however, be taken to ensure that this information remains confidential to the resident. Staff keep a record of resident’s progress, well-being and welfare on a daily basis. This recording presents as thorough and well recorded. The Lead Inspector noted that some of the terminology used by staff is inappropriate, for example “bad boy” and “massive tantrum”. It must be ensured that staff record using terminology that is age appropriate, using descriptions as opposed to judgements. Residents have named key workers from within the staff team. Residents’ care plans are to be reviewed by key workers on a monthly basis, this work is to monitor the achievement of residents’ goals. The Inspectors noted a number of incidents that had occurred in Ashgale House that required reporting to the Commission for Social Care Inspection. This includes incidents of self-harm etc. Staff must be aware of what incidents require reporting to the Commission for Social Care Inspection. This was discussed with Mr Beyene and Ms Elliot and is a previous requirement. The Inspectors discussed with Mr Beyene the need to ensure that staff have full guidance on how to work with residents who challenge the service, physically or otherwise, in Ashgale House. This process is underway. Risk assessments were being developed for residents as part of the care planning processes in Ashgale House. The Inspectors would suggest that any care plans, guidance etc being developed about residents must be dated and signed. Staff can also sign to indicate when they have read and understood residents’ care plans etc. This was discussed with Mr Beyene and Ms Elliot. It was noted that one resident communicated little in English. The Inspectors recommended that staff have access to a list of phases in the resident’s first language in order to facilitate communication. Ashgale House DS0000017514.V270890.R01.S.doc Version 5.1 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): 17 Residents are offered food from the care home’s menus though attention needs to be paid to the content of the menus. One resident confirmed that they could choose what they want to eat. Residents indicated that they enjoy their meals in Ashgale House. EVIDENCE: The Inspector viewed a menu for residents in the ground floor unit. This indicated a range of choices over the week for residents’ breakfast, lunch and dinners. An individual menu was in place that incorporated a residents’ specialist diet. A record is maintained of food eaten by residents in the care home. There is information available for staff on healthy eating. One resident kindly advised the Inspector that they could ‘choose’ what they wanted to eat in Ashgale House, though this was not evident in the menu. Choices must be documented within the care home’s menus. One resident was not aware of what was on the menu for lunch. One resident kindly advised the Lead Inspector that they “liked” their meals in Ashgale House. The Inspectors observed one resident being asked by a member of staff if they would like a “jam sandwich” to eat. Ashgale House DS0000017514.V270890.R01.S.doc Version 5.1 Page 13 The Inspectors noted that food storage facilities in both units did not contain much food; one member of staff, however, went out food shopping later in the day. The Inspector viewed guidance for staff on supporting residents to eat, with associated risks identified. The Inspectors observed that residents were offered drinks by staff during the unannounced inspection and one resident made their own. The Inspector viewed some evidence of residents’ weights having been monitored on a monthly basis, but for one resident this had not been since 20/11/05. It must be ensured that residents’ weights are monitored on a monthly basis where possible and a record maintained. Ashgale House DS0000017514.V270890.R01.S.doc Version 5.1 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): EVIDENCE: These key standards were assessed at the previous unannounced inspection. There remain outstanding requirements regarding Standards 18 & 19. Ashgale House DS0000017514.V270890.R01.S.doc Version 5.1 Page 15 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): EVIDENCE: These key standards were assessed at the previous unannounced inspection. The Lead Inspector viewed an Ashgale House ‘Complaints Procedure’ displayed in a resident’s bedroom. This was presented using a pictorial description of residents’ rights to complain and the procedure/process. Ms Elliot was to arrange to send the care home’s ‘Complaints Procedure to residents’ relatives/significant others etc. The Inspectors discussed with Mr Beyene and Ms Elliot the use of physical restraint in the care home. Ms Elliot stated that guidelines had been put into place for staff indicating that prescribed de-escalation/distraction techniques are to be used when a resident challenges the service in Ashgale House, as opposed to physical restraint. The Inspectors viewed no evidence of the recent use of physical restraint procedures on residents by staff in Ashgale House. The records of a resident’s monies held on their behalf by staff in the care home were inspected. The amounts held accorded with the records. Ashgale House DS0000017514.V270890.R01.S.doc Version 5.1 Page 16 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): EVIDENCE: The key standards were assessed at the previous unannounced inspection. The Inspectors discussed the care home’s progress in complying with the environmental requirements that had arisen with Mr Beyene and Ms Elliot. 9 of the previous requirements have been complied with and 19 remain outstanding. The Inspectors were advised of the work that was underway to comply with requirements. Other requirements observed during the unannounced inspection are noted below. Ashgale House DS0000017514.V270890.R01.S.doc Version 5.1 Page 17 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): 35 Residents’ needs are being met by a staff team that is appropriately trained, although attention needs to be paid to the recording of their induction. EVIDENCE: The Inspector viewed a Training Plan for Ashgale House with record of the training that staff had completed in 2005. This indicated that the required range of training is made available to staff in Ashgale House. Certificates are retained in respect of training attended by the staff team. Mr Beyene reported that all staff have either commenced or completed the NVQ Level 2 in care as is required. One member of staff had completed an NVQ Level 3 in care. Some staff spoke to the Inspector about the NVQ training that they were undertaking. The Inspector discussed staff induction with Mr Beyene. Staff record their progress through induction in conjunction with their manager. Inspection of the induction records indicated that some staff had not completed all the elements of their induction. It must be ensured that a full record is maintained of the induction undertaken by new staff in the care home. Ashgale House DS0000017514.V270890.R01.S.doc Version 5.1 Page 18 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, 39 & 42 Residents benefit from living in a care home that has a Registered Manager, who has the required experience that is updated with training. Resident’s views on the operation of the care home, and those of their relatives and stakeholders, are sought as part of the care home quality monitoring strategy. The report of the annual review of the quality of care that is conducted with regard to Ashgale House must be made available as required. The health, safety and welfare of residents in Ashgale House are largely protected in Ashgale House. EVIDENCE: Mr Beyene is the Registered Manager at Ashgale House and has managed the care home for over a year and has previous management experience. Mr Beyene is considering further management training. In addition Mr Beyene attends staff training sessions. There is also a Deputy Care Manager employed in Ashgale House, Ms Elliot. The Inspector viewed the Annual Business Plan for Ashgale House and Annual Quality Assurance Development Plan during the unannounced inspection. Ashgale House DS0000017514.V270890.R01.S.doc Version 5.1 Page 19 There was indication of audits of the care home being carried out by QA officers within the proprietorial organisation. The care home has sought the views of residents, their relatives and stakeholders regarding the operation of Ashgale House. Samples of the returned questionnaires were viewed and this included positive feedback. Mr Beyene reported that the required monthly visits to the care home by a representative of the Registered Provider are carried out and a report of such a visit that occurred in August 2005 was viewed. Mr Beyene stated that there had been more recent visits to the care home by a representative of the Registered Provider. It must be ensured that the reports of the monthly visits to the care home, carried out by a representative of the Registered Provider, are available in the care home. A Health & Safety policy for the care home was viewed, with evidence of health and safety checks. A number of Certificates of Worthiness were viewed in respect of the care home’s appliance and electrical installation as required. No such Certificate of Worthiness was viewed in respect of the care home’s annual gas appliance and installation testing. This is required. Appropriate fire safety checks and testing were being carried out in Ashgale House. There is an appropriately stocked First Aid box for use in the care home. The Inspectors discussed the need to complete accident reports where accidents and injuries occur in Ashgale House. The Inspectors noted that staff had reported such occurrences in the daily recording and not accident reports. The Lead Inspector tested the hot water tap in the ground floor unit. This ran warm to the touch. The Inspectors noted that the temperatures of fridges in the building were higher than the recommended safe temperature range, namely 5°C. The fridge in the first floor unit kitchen is recorded as having temperatures of 12° C and 17 °C. It must be ensured that fridges in the care home store food at a safe temperature of 5°C. Ashgale House DS0000017514.V270890.R01.S.doc Version 5.1 Page 20 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 2 2 3 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 x 23 x ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 x 33 x 34 2 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 x 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 x x 3 x 2 x x 2 x Ashgale House DS0000017514.V270890.R01.S.doc Version 5.1 Page 21 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 YA1 Regulation 4 Requirement The Statement Of Purpose must include reference to the ‘respite care’ aspect of the service provided in Ashgale House. This must be included with an updated version of the Statement Of Purpose forwarded to the Commission for Social Care Inspection. Care plans must be available for all residents living in Ashgale House. This work must be completed. (Previous timescales of 21/01/05, 10/05/05 & 23/02/06 not met) It must be ensured that significant incidents/events are reported to the Commission for Social Care Inspection, as is required by Regulation 37. (Previous timescale of 23/02/06 not met) It must be ensured that staff record using terminology that is age appropriate, including descriptions as opposed to judgements. Choices must be documented within the care home’s menus. DS0000017514.V270890.R01.S.doc Timescale for action 22/05/06 2 YA6 15 22/04/06 3 YA6 37 22/04/06 4 YA6 12 22/04/06 5 YA17 12 22/04/06 Ashgale House Version 5.1 Page 22 6 YA17 16 7 YA18 13 8 YA19 12 9 YA19 15 10 YA23 17 11 YA24 23 It must be ensured that residents’ weights are monitored on a monthly basis where possible and a record maintained. Ensure that Moving & Handling’ assessments include full details on how staff are to assist residents with moving and handling operations. (Previous timescale of 23/02/06 not met) Ensure that where ‘body maps’ are completed in the event of any bruises or injuries being noticed on a resident, that there clear recorded indication of what follow up had occurred subsequently, e.g. consultation with GP, investigation, reporting to the Commission for Social Care Inspection or completion of the accident book. (Previous timescale of 23/02/06 not met) Care plans and associated guidance for staff must be developed with regard to the prevention of pressure areas and advice for staff on how to work with the resident. (Previous timescales of 26/04/04, 22/01/05, 10/05/05 and 23/02/06 not met) Senior staff must regularly check as correct and sign the accounts of monies held on behalf of residents. This must be commenced. (Previous timescale of 23/02/06 not met) The laminated floor surfaces throughout the building are showing signs of wear and are no longer impervious surfaces. These require replacement. (Previous timescale of DS0000017514.V270890.R01.S.doc 22/04/06 22/04/06 22/04/06 22/05/06 23/04/06 22/05/06 Ashgale House Version 5.1 Page 23 23/03/06 not met) 12. YA24 23 Carpet in the first floor communal areas and lounges are quite stained and must be deep cleaned or (if unsuccessful) replaced. (Previous timescale of 23/02/06 not met) Communal areas of the building require redecoration (both walls and woodwork) in the lounges, corridors and dining areas. (Previous timescale of 23/03/06 not met) Provide seating and tables for residents to use in the garden The paving to the front and side of the building require replacement where the surfaces are cracking and potentially creating trip hazards. (Previous timescale of 23/03/06 not met) The use of wedges to prop open bedroom doors in Ashgale House must be reviewed, with consideration being given to the use of approved door opening devices, in consultation with the Fire Safety Officer. (Previous timescale of 23/03/06 not met) Reseal the shower and baths within Ashgale House (in addition to the flooring in these areas) in order to provide impermeable surfaces throughout. (Previous timescale of 23/02/06 not met) The Ground floor bathroom was very warm with no opening window and an internal extractor fan. Ventilation of this area must be reviewed and improved in order to provide a comfortable environment for residents. DS0000017514.V270890.R01.S.doc 22/05/06 13 YA24 23 22/05/06 14 15 YA24 YA24 16 23 23/04/06 22/05/06 16 YA24 23 22/05/06 17 YA24 23 22/05/06 18 YA24 23 22/05/06 Ashgale House Version 5.1 Page 24 19 YA24 23 20 YA24 23 21 YA24 16 22 YA24 23 23 YA24 23 (Previous timescale of 23/03/06 not met) Redecorate the ground floor bathroom ceiling where stained. (Previous timescale of 23/02/06 not met) The ramping to the front door requires attention where there is a steep drop that requires levelling to offer ease of access to those using wheelchairs to mobilise. (Previous timescale of 23/03/06 not met) The sofas in the first floor unit lounge require deep cleaning or (if unsuccessful) replacement as are stained and worn. The sofas in the ground floor lounge are also showing signs of wear. (Previous timescale of 23/02/06 not met) There is extensive cracking of the walls in one area of the first floor lounge. The cause of this must be eradicated if possible and the area redecorated. (Previous timescale of 23/03/06 not met) The toilet seat in the second floor toilet facility requires secure fitting as was wobbly. (Previous timescales of 02/01/05, 10/05/05 & 23/02/06 not met) 22/05/06 22/05/06 22/05/06 22/05/06 22/04/06 24. YA24 16 25 YA24 23 26 YA24 23 Many curtains in the care home 22/05/06 have shrunk and must be replaced in order to ensure resident privacy in all areas. (Previous timescale of 23/02/06 not met) All fire doors in the building must 22/04/06 close positively. (Previous timescale of 23/02/06 not met) Ventilation in the first floor 22/05/06 laundry must be reviewed, in DS0000017514.V270890.R01.S.doc Version 5.1 Page 25 Ashgale House 27 YA24 23 28 YA24 23 29 YA24 23 30 YA24 23 31 32 YA24 YA24 23 23 33 YA34 19 34 YA35 18 35. YA39 24 order to avoid propping the door open thereby restricting the first floor fire escape route. (Previous timescale of 23/02/06 not met) The first floor unit kitchen surfaces require replacement in the areas that are damaged. (Previous timescale of 23/02/06 not met) The kitchen unit handles in the first floor unit require replacement where missing. (Previous timescale of 23/03/06 not met) The first floor unit kitchen flooring requires replacement, as has a hole in it, therefore making the surface pervious. (Previous timescale of 23/03/06 not met) The hard to clean areas between kitchen cupboards and appliances must be included in the cleaning schedules for the care home. (Previous timescale of 23/02/06 not met) Repair the damaged radiator cover in the ground floor unit hallway. Repair or replace damaged work surfaces in the ground floor kitchen to ensure that the surfaces are impervious. It must be ensured that the care home is in receipt of satisfactory ‘enhanced’ CRB checks prior to a member of staff commencing employment there. (Previous timescale of 23/02/06 not met) It must be ensured that a full record is maintained of the induction undertaken by new staff in the care home. Forward a copy of the report of the annual review of the quality DS0000017514.V270890.R01.S.doc 22/05/06 22/05/06 22/05/06 22/04/06 22/04/06 22/05/06 23/04/06 23/04/06 23/05/06 Page 26 Ashgale House Version 5.1 of care that is conducted with regard to Ashgale House. (Previous timescales of 04/08/04, 02/01/05 and 23/03/06 not met) 36 YA39 24 It must be ensured that the reports of the monthly visits to the care home, carried out by a representative of the Registered Provider, are available in the care home. Ensure that a Certificate of Worthiness in respect of the care home’s annual gas appliance and installation testing is available for inspection. Ensure that accident reports are completed where accidents and injuries occur in Ashgale House. It must be ensured that fridges in the care home store food at a safe temperature of 5°C. 23/04/06 37 YA42 13 23/04/06 38 39 YA42 YA42 17 13 23/04/06 23/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations The Inspectors recommended that staff have access to a list of phases in the resident’s first language, where it is not English, in order to facilitate communication. Ashgale House DS0000017514.V270890.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 Ashgale House DS0000017514.V270890.R01.S.doc Version 5.1 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!