Inspection on 21/06/06 for Ashlea Care Home

This inspection was carried out on 21st June 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ashlea Care Home 14/08/07

Ashlea Care Home 24/11/05

Ashlea Care Home 26/07/05

Ashlea Care Home 21/03/05

Ashlea Care Home 14/03/05

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Ashlea Care Home 1 Kings Road Newark Nottingham NG24 1EW Lead Inspector Jayne Hilton Key Unannounced Inspection 21st June 2006 03:00 Ashlea Care Home DS0000008621.V296715.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 Ashlea Care Home DS0000008621.V296715.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. Ashlea Care Home DS0000008621.V296715.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashlea Care Home Address 1 Kings Road Newark Nottingham NG24 1EW 01636 705206 01636 705334 h2048ashlea.1kingsroad@mencap.org.uk www.mencap.org.uk Royal Mencap Society 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) Jayne Ramsey Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Ashlea Care Home DS0000008621.V296715.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to provide personal care for service users of both sexes whose primary needs fall within the following categories: Learning Disability (LD) (8) The maximum number of service users to be accommodated is 8 Date of last inspection 24th November 2005 Brief Description of the Service: Personal care and accommodation is provided for up to 8 adults with learning disabilities. Ash Lea is a large house located in the centre of Newark and close to shops and all community amenities. There is a large lounge and separate dining room. Service Users are accommodated in single bedrooms on ground and first floors. There are steps at the main entrance and no lift to the first floor. Paved external areas provide space for outdoor activities and seating at the rear of the property. Information about fees obtained by the pre-inspection questionnaire dated 16th May 2006 ranges from£359.18-£423.77 Ashlea Care Home DS0000008621.V296715.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced key inspection was carried out on 21st June 2006, by Regulation Inspector Jayne Hilton for duration of 4 hours. The methodology used included a part tour of the environment, speaking with seven residents in a group and two individually. The manager was unfortunately not in attendance on the day of the inspection. Four staff was spoken with throughout the inspection. A sample of records was examined including two development plans. Direct and indirect observations were also made particularly regarding staff/resident interaction. The inspection was very positive and it was clearly evident that the support given to service users continues to be, of a very high standard. The service users appeared happy and relaxed on the day of the inspection and were looking forward to the impending holidays. The inspector would like to thank the service users and staff for their help and in making her welcome in their home. What the service does well: The residents spoken with confirmed that they were happy at Ashlea and that the staff team had enabled them to develop skills and had provided opportunities they would not necessarily have had anywhere else. Clearly Ashlea provides a service, which balances regulatory obligations with the promotion of rights, respect and responsibility in meeting resident’s needs. Residents know what their support plan is and understand its purpose; they are involved in the development and review of their support. Reviews are held regularly but also when the need arises. Care plans are presented methodically and are well organised. Residents spoken with feel they are offered plenty of opportunity to participate in the day-to-day running of the home. Good risk assessments in place for all residents and these are reviewed regularly. Residents are encouraged to develop independent living skills and to take part in community activities and educational opportunities. Residents are encouraged to retain and learn new skills. Residents spoken with stated that they were happy with the meals provided and that they are involved with choosing and cooking the meals. Ashlea Care Home DS0000008621.V296715.R01.S.doc Version 5.2 Page 6 Ashlea is a clean and comfortable home. Service users bedrooms are personalised. Appropriate pictorial format is displayed around the home. Service users follow individual programmes of daytime activities, and day services staff work in partnership with the residential staff. Independent living skills are developed and encouraged within the home environment with regular times for household tasks. Service users enjoy going out and about and take part in leisure activities with staff. Encouragement and support is given to maintain relationships with families. Service users spoken with, confirmed choice and autonomy within the home. Outcomes for service users are extremely positive and there are no requirements set at this inspection. 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 Ashlea Care Home DS0000008621.V296715.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. Ashlea Care Home DS0000008621.V296715.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 Ashlea Care Home DS0000008621.V296715.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): 1,2,5 Prospective residents have the information they need to make an informed choice about where to live and know that their needs and aspirations will be assessed and met within the constraints of the service provided. Prospective service users needs are assessed, and these are reviewed and kept up to date as required by regulation. Each service users has an individual contract and service users can be confident that the home will meet their needs. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: An up to date Statement of Purpose and Service user guide was seen in the home. There was much evidence by the methodology used to identify that service users needs are well met. Service users were dressed in their individual style and appropriate to the season. Service users were offered individual choices for the teatime meal and care plans reflected individual needs and preferences and were well documented in how these needs were being met. Contracts were seen in care plans. Initial assessments were seen in the two development plans examined. Ashlea Care Home DS0000008621.V296715.R01.S.doc Version 5.2 Page 10 The manager and staff members spoken with demonstrated the necessary knowledge and skills to work with the residents. Observations of staff/resident interaction were calm and mutually respectful. The residents spoken with confirmed that they were happy at Ashlea and that the staff team had enabled them to develop skills and had provided opportunities they would not necessarily have had anywhere else. Clearly Ashlea is unique service, which balances the regulatory requirements with the promotion of rights, respect and responsibility in meeting resident’s needs. Ashlea Care Home DS0000008621.V296715.R01.S.doc Version 5.2 Page 11 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 Service users are involved in their development plans, which reflect the individual’s personal goals. The development plans are generally up to date and new formats for person centred planning is in the development process. Risk taking is clearly promoted both in the home and out and about in the community. Residents know what their support plan is and understand its purpose; they are involved in the development and review of their support. Reviews are held regularly but also when the need arises. Development plans are presented methodically and are well organised. Residents spoken with feel they are offered plenty of opportunity to participate in the day- to- day running of the home. Good risk assessments in place for all residents and these are reviewed regularly. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care/ support plans are drawn up based on initial assessments, and cover aspects of both personal and healthcare. Communication needs are clearly addressed. Each service user’s plan is thoroughly reviewed and updated at Ashlea Care Home DS0000008621.V296715.R01.S.doc Version 5.2 Page 12 least six monthly. Some dates were slightly overdue but the documentation was being reviewed as part of the process and transition to PCP’S The format of the care plan structure has been be reviewed and is under development to current National Minimum Standard expectations and include service users preferred term of address and whether the service user is to be issued with a key to their bedroom door, front door and lockable facilities etc. There were some good overview progress reports for both daily life and activities seen. All of the residents spoken with were familiar with their development plan and contribute to the review process; Clear evidence was seen of their contribution within the plans. Care reviews are held regularly which involve social workers and CPN’s [Community Psychiatric Nurses] as necessary. Residents have an allocated key worker There are individualised procedures for any potential aggressive behaviour. Staff said this was minimal and mainly verbal. Residents confirmed that they are involved in most things to do with the responsibility in ensuring that the environment is clean and tidy. Various rotas were observed for tasks such as cooking, setting the table and housework There was evidence of residents meetings and this time is for anything the residents wish to discuss, including the opportunity to discuss issues regarding the day- to - day running of the home. Information on advocacy groups was noted on the notice board. There were good risk assessments within the development plans, which had been reviewed regularly. There was evidence of service user consultation and signatures of service users, with photographs and a personal profile. Any restrictions on freedom or choice are based on risk assessments, however evidence inn relation to the use of a monitor alarm was not located in the residents support plan. Another service user who is prescribed PRN [as required medication] for challenging behaviour did not have a fully detailed support plan for staff to follow re its use and at what stage this should be given. One service user has developed a pressure area, possibly because of a recent decline in health and mobility. Information was seen within the development plan of district nurse input but there was no support plan detailing what pressure relief equipment is used/needs to be in place for this individual. Cross-referencing of GP, district nurse input and consultant was not in place and some issues were not easy to audit trail. Ashlea Care Home DS0000008621.V296715.R01.S.doc Version 5.2 Page 13 Ashlea Care Home DS0000008621.V296715.R01.S.doc Version 5.2 Page 14 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 Residents are encouraged to develop independent living skills and to take part in community activities and educational opportunities. Residents spoken with stated that they were happy with the meals provided and that they are involved with choosing and cooking the meals. Service users enjoy their food. Service users clearly live a busy and fulfilled lifestyle, where their rights are respected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users follow individual programmes of daytime activities, and most attend day services staff work in partnership with the residential staff. Communication systems are used effectively, and speech and language therapists are consulted. Holidays are arranged, service users informed the inspector that holidays were booked for Norfolk and Devon this year Service users go out in the house car and take part in leisure activities with staff. Most leisure activities are individual, or in small groups to meet specific needs of the service users. Walks out are popular and service users said they Ashlea Care Home DS0000008621.V296715.R01.S.doc Version 5.2 Page 15 go out for meals or to the pub. A boat trip to nearby Farndon was also a favorite. Encouragement and support is given to maintain relationships with families, and weekend visits and telephone contact are recorded in daily notes. A service user told the inspector that she was going to see her parents on the evening of the inspection. Two service users who live in the home consider they are in a relationship. Staff explained what support is given for this but there was a lack of detail within the service users plan of what past input has been given. On the day of the inspection service users were observed to move freely around the home and spend private time in her room as she wished. Service users were noted to have varying responsibilities within the home from laying the table to their own bedroom cleaning. All service users that were able confirmed that they went to bed and got up when they wanted. There is a weekly menu, which demonstrated cooked breakfasts are provided at weekends and service users confirmed this. The menu offers two choices of main meal but there was no evidence that service users could take alternatives in the form of records kept. The meal options offered appeared nutritious and varied, however the inspector recommends that nutritional assessments are included and covered within then care plan process alongside weight evaluation. It was also recommended that staff undertake training in food nutrition, particularly as food charts have been implemented for one service user who has recently been ill. It is the culture in Ashlea that the residents share responsibility for different household tasks. Thus, encouraging independent living skills. Cups of tea are a frequently taken in the home and the inspector was asked several times by several people if she would like one. Staff were observed supporting those who required assistance in an appropriate manner. Special Cutlery was provided where needed and napkins. The crockery was modern and the teatime meal was a pasta and chic pea sauce with side salad chosen and cooked by a service user with staff assistance. Health Eating is promoted and both service users and staff would benefit from training in food and nutrition. One service user enjoys knitting and informed the inspector that he had knitted a total of thirteen blankets, which had been donated to third world countries. Individual likes and hobbies were reflected within service users rooms with Elvis being a firm favourite of music preferences. A service user showed the inspector her personal photographs, which she had stored in special family, box in her room. A pleasant patio area, has been created by residents and staff with pots of flowers and a built in BBQ Ashlea Care Home DS0000008621.V296715.R01.S.doc Version 5.2 Page 16 In house entertainment systems were provided in the main lounge, such as a television, music centre, and DVD and SKY television. Service users confirmed that there are trips out to local restaurants for a meal on a regular basis. From observation and discussion with residents, it was evident that all staff respect residents right to privacy. Residents were observed using keys to their rooms. Lockable facilities were available in the rooms. The atmosphere in the home was relaxed and staff and service residents were seen engaging and interacting with each other. Residents confirmed that mail is given to them unopened and this was witnessed during the inspection. A staff member offered appropriate support for reading the letter to the resident. Ashlea Care Home DS0000008621.V296715.R01.S.doc Version 5.2 Page 17 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 The healthcare needs of residents are generally being met and there are systems in place for monitoring health needs, including behaviours in place The resident’s wishes regarding death and dying recorded and are very detailed and residents are, protected by, good management of medicines in the home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Both of the residents spoken with are fully aware of what their development plan is and what is its purpose and have signed that the plan has been read to them. The home maintains good links and relationships with necessary resources such as Community Learning Disability Teams and community psychiatric nurses. Health care is well monitored, and notes are kept of advice given by medical professionals. Service users are encouraged to have an annual wellperson check, and other checks such as regular smear tests, breast screening and hearing checks and these are evidenced within the care plan structure. Weight charts were completed well, but these did not identify issues regarding weight gain and weight loss. The record should be reviewed and incorporate an action/comment box which staff would use to identify significance of Ashlea Care Home DS0000008621.V296715.R01.S.doc Version 5.2 Page 18 changes in the service user’s weight, including well being and mental health or used in conjunction with a nutritional assessment and care plan. Behaviour management plans were seen. From talking with residents and staff it was apparent that personal support is flexible and the overall culture of the home is to promote choice, control and independence. Equality and diversity is promoted and some staff had recently attended a recent training course on the topic. A brief assessment was made of the management of medicines in the home. Policies for medicines management are kept in the office and copies of these are kept with the medication. The drug error policy is sited where staff can instantly access this, informs staff that any errors in medication procedures must be reported to CSCI under regulation 37 requirements. One medication error did occur in the last few months and has been dealt with appropriately. There was a medication profile and record of medication reviews and changes to medication. Medication record sheets were completed satisfactorily. The BNF [British National Formulary] was slightly out of date. Ashlea Care Home DS0000008621.V296715.R01.S.doc Version 5.2 Page 19 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): 16,18 The home has a complaints policy which, residents are aware of and know how to use Service users are protected from abuse, neglect and self-harm and the provision of training for staff is provided. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a system for which all concerns and complaints can be recorded in, including if and what necessary action has been taken. There were no concerns reported since the last inspection. The residents spoken with are all fully aware of the complaints procedure and all information on the procedure is up to date and includes how to contact the Commission for Social Care Inspection in picture format also. The NCPVA [Nottinghamshire Committee for Protection of Vulnerable Adults] folder was seen in the home and staff confirmed they had training. Certificates were also seen to support this. There have been no incidents in relation to Safeguarding Adults issues at the home. Staff members spoken with confirmed they were aware of the whistle blowing policy and General Social Care Council Code of practice and a copy was displayed on the staff notice board. Service users financial records were examined and were satisfactory. Ashlea Care Home DS0000008621.V296715.R01.S.doc Version 5.2 Page 20 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): 24,30 Ashlea is a clean and comfortable home, which provides adequate communal space. Service users bedrooms are personalised. The toilet and bathroom provision is adequate to meet the needs of all service users. The service users independence is maximised by the facilities and equipment in the home, however a ramp is needed to ensure disabled access and this is being provided shortly. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is well maintained and provides a good standard of homely, comfortable and attractive accommodation in pleasant surroundings. There was a plaster crack in the staff room which requires attention. Bedrooms seen were very personalised with service users own furniture and chosen décor, including personal photos, artwork and posters etc. The home has sufficient bathrooms and toilets. The ground floor bedrooms provide accommodation for those who find difficulty with mobilising on the stairs. Disabled access to the front door is being provided shortly. Ashlea Care Home DS0000008621.V296715.R01.S.doc Version 5.2 Page 21 Risk assessments were seen for radiators and some are of the low surface type or covered. The radiator in the dining room is sited close to the dining table chair and should be covered before the winter months. From observation and being shown around the home, the premises appeared clean, hygienic and free from offensive odours. Disposable gloves were noted to be available and liquid soaps are provided in all bathrooms and the kitchen but there was no provision of these for use in the laundry. Staff said they use the kitchen but this presents a risk of cross infection and gloves, soap and paper towels should be provided in the laundry also. There are two washing machines but none have a sluicing facility. As there is an identified need within the service user group for this facility, consideration should be made to replace a washer with one with a sluicing programme. Service users were prompted by staff o wash their hands before tea. A resident and a staff member was observed wearing an apron when preparing food on the day of the inspection. Ashlea Care Home DS0000008621.V296715.R01.S.doc Version 5.2 Page 22 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): 32,34,35,36 Resident’s rights and best interests are safeguarded by the homes record keeping policies and procedures. Service users are supported by a well supported and supervised, committed staff team training and recruitment. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff have job descriptions and roles, and their limitations are discussed within regular staff meetings as well as individual meetings. The staff rota was examined at this inspection. There are three staff on duty at peak times two staff at other times and one member of staff sleeps in. Domestic staff are employed. The manager and deputy work management hours between them. The `rota allows for activities and escort duties as needed. The recruitment files were not inspected due to the manager being on leave, however the lead support worker informed the inspector that Mencap have robust recruitment practices and that two newly appointed staff are waiting for CRB’s prior to them starting work at the home. The training programme 2006/2007, demonstrates that mandatory training subjects and other specific identified training is provided for staff. All staff receive mandatory training in Infection Control, fire safety, first aid, food hygiene, manual handling and health and safety. Accredited Medicines Ashlea Care Home DS0000008621.V296715.R01.S.doc Version 5.2 Page 23 management training is also provided for those authorised to dispense medication and competency assessments are said to take place. Evidence was seen of induction records and supervision records and regular staff meetings which staff also confirmed were taking place. Ashlea Care Home DS0000008621.V296715.R01.S.doc Version 5.2 Page 24 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 Service users benefit from a well run home and record keeping on the whole was good. Attention is needed to ensure that staff remembers undertake fire safety tests weekly. Service users are confident their views underpin all self- monitoring review and development by the home. The health and safety and welfare of service users is generally well promoted and protected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager is experienced and qualified in social care and has worked at the home for several years. The manager is registered with the Commission and has attained the Registered Managers Award. She was also qualified to assess other staff for their National Vocational Qualifications. Staffs spoken with demonstrated confidence in the mangers leadership and said that the staff team were strongly bonded and work well together. Ashlea Care Home DS0000008621.V296715.R01.S.doc Version 5.2 Page 25 Quality monitoring was evidenced by Quality networking visits, Quality Tree and regulation 26 visits. There are records of refrigerator and freezer temperatures being monitored; all substances hazardous to health (COSHH) have been assessed for risks and are held securely. The Gas safety and electric circuit test certificates were up to date. Weekly fire tests were not satisfactory as some weeks had been missed and attention to this is recommended. There was evidence of systems in place to prevent legionella and records regarding water outlet temperatures were seen. Evidence of generic risk assessments were seen and evidence of fire safety risk assessments seen. Portable appliance tests were examined and found to be satisfactory. A contingency plan for emergencies should be devised. All other records seen during the inspection are maintained, up to date and accurate. Accident records are kept in accordance with Data Protection. All records are kept secure. The Environmental Health Officer last visited on 21/12/05 and said that food temperature probing needed logging-evidence was seen that this was now in place. External doors were alarmed at night and there was a policy in place for lone working. All staff completed training in safe working as part of their induction. Ashlea Care Home DS0000008621.V296715.R01.S.doc Version 5.2 Page 26 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 3 3 X 4 X 5 3 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 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 X 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 3 X 3 X Ashlea Care Home DS0000008621.V296715.R01.S.doc Version 5.2 Page 27 NO 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. Standard Regulation Requirement Timescale for action 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 2 3 4 5 6 7 8 Refer to Standard YA6 YA19 YA6 YA19 YA17 YA17 YA24 YA30 YA30 YA42 Good Practice Recommendations Attention to detail in support planning in relation to follow ups and cross referencing Ensure development/support plans contain information in relation to pressure area needs, for PRN medication and in relation to authorisation for the use monitor alarms. Staff should undertake training in food and nutrition Evidence should be provided of resident meal choices Repair the plaster damage in the staff sleep in room Supply gloves, paper towels and liquid soap in the laundry Provide appropriate sluicing facilities. Ensure fire alarm tests are carried out every seven days Ashlea Care Home DS0000008621.V296715.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Ashlea Care Home DS0000008621.V296715.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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