Inspection on 09/01/07 for Ashglade Rest Home

This inspection was carried out on 9th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ashglade Rest Home 09/12/08

Ashglade Rest Home 11/11/05

Ashglade Rest Home 20/05/05

Ashglade Rest Home 02/11/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Ashglade Rest Home Ashglade Rest Home 178 SouthBorough Road Bickley Bromley Kent BR2 8AL Lead Inspector David Lacey Unannounced Inspection 9th January 2007 10:00 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 Ashglade Rest Home DS0000061312.V318232.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 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. Ashglade Rest Home DS0000061312.V318232.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashglade Rest Home Address Ashglade Rest Home 178 SouthBorough Road Bickley Bromley Kent BR2 8AL 020 8467 0640 020 8295 1740 ashgladecare@tiscali.co.uk 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) Chislehurst Care Limited Mrs Denise Ann Gill Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Ashglade Rest Home DS0000061312.V318232.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th November 2005 Brief Description of the Service: Ashglade is an Edwardian detached three-storey house, which has been converted to provide care for up to 15 older people. It is situated in a residential area on a main bus route between Petts Wood and Bromley. There is limited parking to the front of the property. The accommodation for service users is on the lower two floors. A shaft lift provides access between these floors. There is a garden at the back of the home, which can be accessed by a ramp. Ashglade Rest Home DS0000061312.V318232.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection included an unannounced visit to the home. During the visit, I spoke with some of the service users, members of staff, the manager, the company’s nursing director and a relative visiting the home. I inspected parts of the premises and examined various pieces of documentation. Twelve service users completed written comment cards and their views have been included in this report. The home’s present fees range from £378 - £550 per week. What the service does well: What has improved since the last inspection? The home has made sure that cleaners have enough time to do their job effectively. Cleaning equipment and materials are stored safely. Action has been taken to ensure that service users can access the emergency call system at all times. Ashglade Rest Home DS0000061312.V318232.R01.S.doc Version 5.2 Page 6 The home’s manager has become registered with the commission following a process of assessment. 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. The summary of this inspection report can be made available in other formats on request. Ashglade Rest Home DS0000061312.V318232.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashglade Rest Home DS0000061312.V318232.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4, 5 (6 does not apply to this home). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users may visit the home before making a decision whether to move in. Service users’ needs are assessed before admission. All service users receive a contract with terms and conditions. EVIDENCE: Service users’ needs are assessed before they move into the home, to ensure the home is suitable. The home’s manager takes the lead with this process. Service users may also be reassessed, for example following a stay in hospital. It was evident that, on occasions, a service user’s needs had changed such that the home was no longer suitable and an alternative placement had been found. Service users receive contracts with the home that set out the terms and conditions of their residency. A sample of these was seen during the inspection visit. Of the twelve service users who provided written comments to the Ashglade Rest Home DS0000061312.V318232.R01.S.doc Version 5.2 Page 9 commission, six stated they had received contracts, four that they could not remember whether they had received one, and two service users stated they were not sure whether they had received a contract. From observation, discussion and comments received, service users’ assessed needs were being met. Service users said they were looked after very well by staff at the home. Staff on duty showed interest in service users’ welfare. It was evident from discussions and from records made by the manager that people considering whether to move into Ashglade can visit the home to have a look at its facilities and meet with service users and staff. Of the twelve service users who provided written comments to the commission, eight stated they had received enough information before deciding whether to move into Ashglade, and one service user that she had not received enough information. Three service users stated they could not remember whether they had received enough information at the time of moving into the home. A service user commented about her meeting with the manager when she had visited the home with her family, “it was extremely good and covered everything we needed to know and it turned out to be 100 correct”. Ashglade does not offer intermediate care, thus the standard for this is not applicable to the home. Ashglade Rest Home DS0000061312.V318232.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive the health care they need. Care plans give staff guidance about how to meet individual service users’ needs. Medication is being managed appropriately. EVIDENCE: Care plans selected for inspection during the visit had been drawn from assessment of the service users’ needs. There was some evidence that service users and/or their representatives had been involved in the care planning process and had been invited to sign their care plans. The plans seen had been reviewed regularly. Risk assessments for tissue viability and nutrition had been recorded and continence needs assessed. Service users said they could see a doctor as they needed, and this was also evident from information recorded on service users’ plans. District nursing services are provided to service users who need nursing input to their care. Other health care services are made available either through the GP or privately. All of the twelve service users who provided written comments to the commission stated they received the medical support they needed. Ashglade Rest Home DS0000061312.V318232.R01.S.doc Version 5.2 Page 11 Of the twelve service users who provided written comments to the commission, seven stated they always received the care and support they needed. Five service users stated they usually received this. A service user commented, “every member of staff is kind, considerate and generous with their time”. Another stated she was, “satisfied with the care received”. A visiting health care professional has provided positive written comments to the CSCI about the home and its service provision. Comments included, “well run and organised”, “[service users] always well presented and well cared for”. Staff members who administer medication have received appropriate training and have been assessed as competent to undertake this procedure. On the day of the inspection, medication was being stored appropriately, including medication requiring refrigeration and controlled drugs. Staff rotas show the home’s ‘designated responsible person’ for each shift, and this member of staff holds the drug keys. The manager carries out monthly medication audits, using the provider’s pre-designed format for this purpose. The most recent audit (December 2006) was examined during the visit. The homely remedies protocol is a generic document supplied to the PCT by the prescribing GP, which does not identify Ashglade specifically. It is understood this protocol has been seen in the recent past by the CSCI pharmacy inspector. The home may wish to ensure it is named in the document when it is next reviewed. Ashglade Rest Home DS0000061312.V318232.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can choose to take part in various planned activities. Contact with families and friends is encouraged and supported. Service users are offered a choice of food from a menu and are served their meals in pleasant surroundings. EVIDENCE: The activities programme for January 2007 was on the notice board in the hallway. Service users told the inspector they enjoyed these activities. One said, “it helps to keep me active”. Of the twelve service users who provided written comments to the commission, seven stated there were always activities arranged that they could take part in. Two service users stated this was usually the case. Three service users stated there were sometimes activities they could take part in, with one commenting, “I prefer to read”. During the morning of the visit, the home’s activities coordinator set up group activities for service users in the main lounge. There is a loop system in this room to help people who have impaired hearing. The coordinator also works with those service users who prefer to relax on their own doing individual activities, such as reading newspapers and watching television. For example, service users who like reading may be accompanied to the local library, which Ashglade Rest Home DS0000061312.V318232.R01.S.doc Version 5.2 Page 13 is within close walking distance of the home. The inspector heard that, at times when the coordinator is not in the home, service users get more stimulation than they used to and that this was attributable to a new management approach. The coordinator works on three mornings each week and carers lead activities for service users at other times. Trips out from the home are arranged, for example, a visit to Bromley shopping centre before Christmas and a trip to a local garden centre. A service user said she chose when she got up in the morning and when she went to bed. Care plans showed service users’ preferences in relation to different aspects of their lifestyles. Service users have been encouraged to bring personal possessions and mementos from home, to personalise their own bedrooms. Discussions with service users confirmed they are supported to keep in touch with their families and friends as they choose. The inspector also met with a relative who visits the home regularly, who said he was always made welcome in the home. The home has a small visitors’ room so that service users can meet with a visitor privately, other than in their bedrooms. Lunch was a relaxed affair, served in the dining room. A printed menu was on each table, with tablecloths, tablemats, napkins, condiments, jug of juice and gravy boat. Service users can choose to eat their meals in their rooms if they wish, and a service user did so on this occasion whereupon her meal was taken to her on a tray. Service users said they enjoyed the lunch served during the inspection and made positive comments in general about the food provided. Two service users said the cook knew what they liked and disliked and they could ask for an alternative choice of meal. Of the twelve service users who provided written comments to the commission, seven stated they always liked the meals provided, four that they usually liked the meals, and one stated that she sometimes liked them. Menus and records of food served showed that a balanced, nutritious diet was provided to service users. The inspector recommended the format used for recording the food provided be amended to also show the initials of the service user(s). Ashglade Rest Home DS0000061312.V318232.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an appropriate complaints procedure. Complaints are addressed but the recording of information about each complaint received needs improvement. The home ensures that service users are protected from abuse. EVIDENCE: The home has a complaints procedure in place, which is made available to all service users in the service user guide. The commission has not received any complaints about Ashglade since the previous inspection. The home’s complaints file was examined and found to contain two entries since the previous inspection. For one of these complaints, there was no record of its investigation or evidence of a response to the complainant. The home’s complaints procedure states a response will be made to a complaint within 28 days. The manager said a response had been made but it had been verbal and no record of the conversation had been made. There was a written response on file for the other complaint received but no record of investigation. The home’s complaints records must include details of any investigation and action(s) taken. Service users and a relative who spoke with the inspector said they had not needed to make any complaints. The relative said whenever he had any concern, he had spoken to the manager or a staff member and the matter had been addressed. Service users said if they were worried or unhappy about Ashglade Rest Home DS0000061312.V318232.R01.S.doc Version 5.2 Page 15 something, they would speak with the manager or another staff member. The manager said she has daily contact with all service users and regular contact with their visitors, and encourages them to discuss any concerns they may have. Of the twelve service users who provided written comments to the commission, eleven stated they always knew who to speak to if they were unhappy and how to make a complaint. One service user stated that she sometimes knew this. The home has policies and procedures for adult protection and whistle blowing. The local (Bromley) interagency adult protection guidelines are available in the home. Relevant training is provided to staff members, who are given access to local authority training and the home’s DVD-based training pack. With the latter, staff are required to view the DVD and complete questionnaires to show their understanding of the material. Staff spoken with showed understanding of their responsibilities in relation to protecting service users. Ashglade Rest Home DS0000061312.V318232.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s environment is fit for its stated purpose. The home is clean, tidy and generally well maintained. EVIDENCE: The home was clean and tidy on the day of inspection. No unpleasant odour was evident. The home had considered a previous recommendation about the number of hours provided for cleaning the home, and a housekeeper is now on duty each day for 2.5 - 3 hours. Of the twelve service users who provided written comments to the commission, eleven stated the home was always fresh and clean and one said this was usually the case. A service user commented, “everyone makes every possible effort to keep the house fresh and clean”. Another stated, “Would not like to go back home now – very happy”. The temperature in the building was comfortable. Two service users who had been resident for some years said the home was always nicely warm in the winter. Ashglade Rest Home DS0000061312.V318232.R01.S.doc Version 5.2 Page 17 The bedrooms inspected were well decorated and furnished, with the exception of a locking facility in some of the rooms seen. The nursing director gave assurance this will be provided shortly for all service users as part of renewing furnishings as, at present, some bedrooms have a locking drawer whereas others do not. There were some good orientation aids for service users, such as clocks with easily readable faces and a calendar in the main hallway. A chalkboard in the dining room had “9th Jan 07” in indistinct chalking, and it was agreed that staff would ensure this board is always readable and the date would be written in full, including the day of the week. The hot water temperature in the ground floor bathroom was comfortable to the inspector’s touch, though the thermometer reading was only 32 degrees C. The inspector raised this with the manager, who said the thermometer would be replaced. The hot water flow to the upper floor bathroom was poor and its temperature was 47 degrees C, using the home’s thermometer, though comfortable to the inspector’s touch. This was raised with the manager and nursing director who were able to show that the water flow problem in this bathroom had been identified and repair had already been ordered. It was agreed staff members would be reminded to report any apparently faulty bath thermometers. It was understood that thermostatic valves have been installed to all wash hand-basins, as well as the baths. Two service users told the inspector that they enjoyed bathing, as the water was always comfortably hot and the bathrooms warm. The basement is also used as a storage area and it was noted that discussion had taken place at the previous inspection about the need for the overall space to be organised with walls and flooring that are readily cleanable. This had not yet been addressed. Ashglade Rest Home DS0000061312.V318232.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels and skill mix are sufficient to meet the needs of the service users in residence. Staff members listen to service users and act on what they say. Recruitment practices are generally satisfactory but two aspects have been identified as needing improvement. Staff are supported to undertake training relevant to their work in the home. EVIDENCE: Staffing levels at the home on the day of inspection were sufficient to meet the needs of the service users. The home was not full, having thirteen service users in residence. The staff rota for the previous week was seen, and showed that at least two care staff members were on duty on each day shift. Discussion took place with the nursing director and the registered manager about the present arrangements for night staffing. These are that one staff member is awake and one is sleeping-in. Normally, the sleep-in staff member is one of the two nurses resident in the upper floor staff flat. If both of these nurses are away, another staff member sleeps-in, using a folding bed in the visitors’ room. The nursing director said she was clear that this night staffing arrangement was sufficient to meet the needs of the current service users. The director also confirmed that the occasional use of the visitors’ room by sleep-in staff had never impinged on service users’ use of this facility. She confirmed that the night staffing levels would be strengthened if necessary, for example, if a service user’s needs changed so that s/he required constant attention. Ashglade Rest Home DS0000061312.V318232.R01.S.doc Version 5.2 Page 19 An administrator spends one full day each week in the home, giving support to the manager. Comment has been made about housekeeper staffing above in the ‘Environment’ section. All of the twelve service users who provided written comments to the commission stated that staff always listened and acted on what they say. Six service users stated that staff were always available when they needed them, six said this was usually the case. A service user commented that, “[I am] very happy, people friendly and helpful”. A carer explained to the inspector how she had applied for her post, been interviewed and selected for the job, and undertaken an induction programme. She also talked about other training she had completed since taking up her post. The inspector examined her recruitment file, which contained the recruitment information required and documentary evidence of the training the carer had completed. Another recruitment file sampled had most of the information required. However, it did not have evidence that a two-year gap in the applicant’s career history had been explored. The manager reassured the inspector that exploring such gaps was her usual practice when recruiting staff and that she would ensure this is always made evident. A requirement in this respect has been made. One of the two references on file was a personal reference, and it is recommended that, whenever possible, such references are followed up with a telephone call as a further check of validity. Staff are supported to obtain NVQ’s that are relevant to their work. The inspector met with two staff members who had completed NVQ2 in care recently. They had enjoyed the programme and gave examples of its usefulness for their work with service users in the home. The cook was being supported to undertake NVQ in catering. Ashglade Rest Home DS0000061312.V318232.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home now has a manager whose fitness has been assessed by the commission. Service users may be assured the home safeguards their financial interests. The home promotes the health and safety of its service users, staff and visitors. EVIDENCE: The home’s manager, Denise Gill, has been in post since October 2005. Since the previous inspection, Mrs Gill has become registered with the commission following a process of assessment. Her previous experience and qualifications are relevant to managing a care home for older people. She is a registered nurse and completed the Registered Manager’s Award in May 2006. During the inspection, Mrs Gill showed clear understanding of her role as the manager of a care home for older people. The inspector heard comments from service users, relative and staff that the home has improved since Mrs Gill had been in post. Ashglade Rest Home DS0000061312.V318232.R01.S.doc Version 5.2 Page 21 It was evident that the manager has daily informal contact with each service user resident in the home. From discussion, it was apparent that service users’ meetings are held. However, minutes of these meetings could not be located by the manager during the inspection visit and therefore were not seen on this occasion. The company’s nursing director makes monthly visits to the home during which the quality of services is monitored. Copies of written reports of these visits have been supplied to the commission. It is recommended that service users are surveyed, with the results being published and made available to service users and their representatives. The inspector did not see or hear any evidence of shortages of resources for the care home. The CSCI registration certificate and a valid certificate of liability insurance were displayed prominently in the hallway of the home. The manager confirmed that the home does not hold service users’ personal money. Service users either manage their money themselves or have relatives or advocates who manage their finances on their behalf. The home invoices service users’ families or other representatives for ‘extra’ charges, such as hairdressing. The manager had addressed a previous requirement to keep the home free from hazards to service users’ safety whenever possible. The local authority (Bromley) environmental health department had carried out a food hygiene inspection in March 2006. Three recommendations had been made for improvement, which the manager confirmed had been addressed. The home’s fire information was seen. The fire alarm is tested each week and staff receive fire training. Fire drills are conducted regularly, including at times that night staff can attend. A previous requirement about the fire exit door leading from bedroom 8 had not been met in full, in that consultation with the fire officer had not taken place. The nursing director and the manager agreed to ensure such consultation is undertaken. The service user resident in room 8 spoke with the inspector. She said she chose the room as it has a nice view over the back garden and she could put bird feeders outside her window. She said she is happy about the fire exit door, “it doesn’t bother me”, and she knew people would need to use it if there was a fire. She did not wish to lock her bedroom door. A sample of servicing records showed they were up to date. For example, servicing records seen for the over-bath hoists matched the service sticker on the hoists and were within the appropriate timeframes. Ashglade Rest Home DS0000061312.V318232.R01.S.doc Version 5.2 Page 22 A previous requirement about emergency call points had been met. Call alarm points were seen to be available in all areas to which service users have access. Call alarms were within service users’ reach, for example, the inspector observed that for a service user with residual weakness to her left arm staff members had placed the call alarm cord by her right hand. Ashglade Rest Home DS0000061312.V318232.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 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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 X X 3 Ashglade Rest Home DS0000061312.V318232.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP38 Regulation 23(4) Requirement Consult with the Fire Officer regarding a means of escape/privacy of service user. Previous requirement. Timescale for action 28/02/07 2 OP16 22 The registered person must 28/02/07 ensure that a record is kept of all complaints made, which includes details of any investigation and any action taken. The registered person must ensure that a full employment history, together with a satisfactory written explanation of any gaps in employment, is obtained before an applicant begins work in the care home. 31/01/07 3 OP29 19 Schedule 2 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 Good Practice Recommendations DS0000061312.V318232.R01.S.doc Version 5.2 Page 25 Ashglade Rest Home 1 Standard OP15 The registered person should ensure that the format used for recording the food provided is amended to also show the initials of the service user(s) concerned. The registered person should ensure that each service user has a lockable storage space. The registered person should ensure that, whenever possible, personal references that are not on headed paper or with a company stamp are followed up with a telephone call as a further check of validity. The registered person should ensure that service users’ views are surveyed, with the results being published and made available to current and prospective users and their representatives and other interested parties, including the commission. 2 3 OP24 OP29 4 OP33 Ashglade Rest Home DS0000061312.V318232.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Ashglade Rest Home DS0000061312.V318232.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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