Inspection on 16/05/06 for Ashlea Court

This inspection was carried out on 16th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Ashlea Court 21/01/09

Ashlea Court 04/05/07

Ashlea Court 16/12/05

Ashlea Court 01/07/05

Ashlea Court 11/11/04

Ashlea Court 29/06/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Ashlea Court Ashlea Court Church Lane Waltham Grimsby North East Lincs DN37 0ES Lead Inspector Mrs Jane Lyons Unannounced Inspection 16th May 2006 09:00 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 Ashlea Court DS0000057246.V295921.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. Ashlea Court DS0000057246.V295921.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashlea Court Address Ashlea Court Church Lane Waltham Grimsby North East Lincs DN37 0ES 01472 825225 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) Winnie Care (Ashlea Court Grimsby) Ltd Mrs Lesley Pearce Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (48) of places Ashlea Court DS0000057246.V295921.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. that the home can accept five persons under the age of 65 years (and no other under that age) until those persons reach the age of 65 years or terminate their contract with the home. 16th December 2005 Date of last inspection Brief Description of the Service: Ashlea Court is located in a quiet residential area, close to all village amenities. The home provides care including nursing for up to 48 residents over the age of 65 and included in that total has five places for persons under the age of 65. The building is of a modern construction; purpose built in 1995 and in January 2002 had a 10 -bed extension registered. Furnishings and fittings are of a high standard. A passenger lift and stairs are provided to access both floors. All bedrooms are for single occupancy and meet the standard regarding minimum standards, 36 of the bedrooms have en- suite facilities and there is a range of assisted and non- assisted bathing facilities within the home. There are four lounge areas and a tearoom for residents and visitors to use. There are two courtyard areas, one of which is enclosed. Ample car parking spaces are available. Weekly fees are: £400- £550. The home operates a system whereby the fees include a third party contribution. Additional charges are made for the following: toiletries, newspapers/magazines, hairdressing, chiropody, transport to appointments and escort fees. Information on the service is made available to prospective and current service users via the statement of purpose, service user guide and inspection report. Documents are made available prior to and following admission, copies are always held in the reception area. The home currently operates a waiting list. Ashlea Court DS0000057246.V295921.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced key inspection and took place over 1 day in May 2006. Prior to the site visit 5 relative surveys were posted out of which 3 were returned, 12 service user surveys of which all were returned and 10 staff surveys of which 4 were returned. Surveys were also sent to 4 health professionals and 4 care managers and 2 returned; 2 health professionals were contacted via the telephone. During the visit the inspectors spoke to the registered provider, manager, administrator, four staff, twenty residents and four relatives to find out how the home was run and if the people who lived there were satisfied with the care and facilities provided. The inspector looked around the home and looked at some records. Information received by us over the last twelve months was considered in forming a judgement. Prior to the visit the inspector referred to notifications sent to the Commission for Social Care Inspection, the event history for the home over the past year and the completed pre- inspection questionnaire. The site visit was led by Regulation Inspector Mrs.J Lyons who was accompanied by Regulation Inspector Mrs.K Emmerson, the visit lasted nine and a half hours. What the service does well: The home provides very good facilities; all areas were decorated and maintained to a high standard, very clean and tidy. There was a very relaxed and homely atmosphere in the home, residents were observed to be very settled and comfortable in their surroundings. One resident wrote on her survey that she had lived very happily in the home for the last four years. The home has an enthusiastic staff team who are keen and motivated to ensure that the care provided is of a good standard. The staff are eager to develop their skills further with the relevant training and support which results in residents being well cared for. One resident wrote in her survey “I am well looked after in every way” and recent thank you letters to the home detailed, “The care is second to none at Ashlea Court” and “ All the team are fantastic from the cleaning staff, carers, cooks to all the admin staff”. Ashlea Court DS0000057246.V295921.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Service users said that they were happy with the way their complaints are dealt with, however the manager must ensure that records are clearly maintained of all complaints investigations, outcomes and contact with the complainant to demonstrate positive management systems are in place. The manager has improved the programme of audits and surveys which support the quality assurance system; however she now needs to consider how she is going to develop the service where residents have made negative comments. Only then will service users’ contribution to the running of the home be of some purpose. This requirement has been outstanding since the introduction of the National Minimum Standards and efforts must be made to prioritise the full implementation of a formal programme. Residents praised the care staff, their skills and attitudes, however staff do not get regular formal supervision sessions, therefore the manager cannot demonstrate how she is assessing/ monitoring their continued ability. Had this been in place then the manager would have made sure the improvements needed in the care plan documentation happened as they do not ensure residents needs are met. Ashlea Court DS0000057246.V295921.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ashlea Court DS0000057246.V295921.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashlea Court DS0000057246.V295921.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4,5 and 6 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users and their relatives were provided with sufficient information to help them decide if the home was right for them. The admission process was thorough with staff ensuring that new residents felt welcome and secure. EVIDENCE: Five service user files were case tracked; pre-admission assessments were evidenced and service users confirmed that they were either assessed in their own homes or in hospital. The admission procedure was adequate to guide staff on the actions to be taken to ensure that new residents needs are properly assessed and planned for. Publicly funded service users had copies of the local authority assessment/ care plan on file. Signed contracts and terms/ conditions documents were in place. Ashlea Court DS0000057246.V295921.R01.S.doc Version 5.2 Page 10 There was good evidence to demonstrate that care staff were accessing a broad range of service specific training which will help ensure that they have the skills to enable them to deliver up to date care methods and have a better understanding of the varied conditions common to the elderly. A number of service users confirmed that they had taken the opportunity to visit the home prior to admission although most said that their families or friends had visited the home to assess its suitability, which had been a satisfactory arrangement. Service users and relatives spoken to during the visit told the inspector that they had chosen the home for reasons such as: the friendly atmosphere, the facilities/ location and the kindness and friendliness shown by the staff. One service user had written in her survey “Fell in love with the place, its so light and bright. I love it here.” Another had written “It was marvellous, different to what I though it would be, staff took all my fears away”. Relatives of a prospective service user were visiting the home during the inspection visit to discuss last minute details with the manager; they confirmed that they were satisfied with all the information they had been given and a copy of the inspection report was made available to them. The home does not provide intermediate care therefore NMS 6 is not applicable. Ashlea Court DS0000057246.V295921.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users health and personal care needs are generally met, however the quality of the ongoing maintenance and up dating of the care plans is inconsistent. Medication procedures need to improve to enable staff to make sure service users get the medication they need or are reviewed. EVIDENCE: Case Tracking took place for five service users. The methodology used was a physical examination of care plans, written surveys to service users, relatives and health care professionals, discussions with health care professionals, discussions with family members and direct observation on the day. At the previous inspection visit significant improvements had been made to the care documentation however at this visit it was clear that the standard of the documentation was not consistent. A number of the care plans had been clearly written, detailing very clear care support directions for staff and had been evaluated regularly whilst other plans were more general and had not been evaluated regularly. Advice was given to rewrite one of the care plans where the service users’ needs had changed significantly since admission and Ashlea Court DS0000057246.V295921.R01.S.doc Version 5.2 Page 12 although the plans had been updated they could be much clearer in describing the current care support in place. There were risk assessment tools for mobility, falls, tissue viability, bed rail provision, medication, nutrition and general issues; all high risk areas identified had been reviewed regularly and care plans in place to support appropriate care provision. Service users spoken to confirmed that they were aware of the care programmes but had no interest in reading them. Service users or their relatives had signed agreement to the assessment during the admission process. There was evidence that service users needs had been formally reviewed; one service user accesses support from the Rehabilitative Medicine Team and multi service reviews were held six monthly. Current concerns regarding her tissue viability needs were being followed up with the wheelchair services. Service users told the inspectors during the visit and also wrote on the surveys that they were satisfied with the standards of care provided, they considered that the staff listened to them and always treated them with dignity and respect. Relatives told the inspector that communication with the staff was very good; they were always informed of any appointments, changes in condition and when events such as falls had occurred. The inspector spoke with two district nurses who regularly visit the home: they confirmed that they were satisfied with the levels of care support in the home and that communication with the staff was good. Medication systems were examined; policies and procedures were in place which covered all areas of management however they are very minimal and now need to be reviewed and developed to provide more detailed and up to date instructions and methodology for all aspects of the system. Storage of all medications was found to be satisfactory; the clinic room temperatures are monitored closely; external and internal medications were stored separately and stock control was effective. Controlled medication was checked and found to be stored and recorded satisfactorily. Transcribing records were checked and found to be satisfactory, medication administration records were satisfactory. Records of receipt and returns of medication were found to be unclear and management should review this. There was one service user receiving Percutaneous Endoscopic Gastrostomy (PEG) feeding and there was evidence that this was managed effectively. One of the Registered General Nurse’s has lead responsibility for this area and a number of the qualified and senior care staff have accessed the accredited medication courses. Ashlea Court DS0000057246.V295921.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The service users were seen to experience a full life with opportunities to take part in varied activities. The meals in this home offer both choice and variety. EVIDENCE: Residents are able to take part in a variety of valued and fulfilling activities, both in-house and within the community. One resident had written on her survey that “I’ve been very happy here for the last four years”. Residents meetings are held regularly and well attended; there was evidence that areas such as activities, entertainments and trips out are regularly discussed and suggestions from residents are followed through. There is an activity co-ordinator employed in the home who provides support within a group or one- to one basis. Activities such as yoga, quizzes, games, videos, craft and gardening are organised weekly; entertainment such as singers and pianists are arranged and residents also have the opportunity of visiting local places of interest such as shops, garden centres, restaurants, public houses and the sea front in the homes’ mini bus. Manicures and hand massage are also popular with the female residents and one resident was enjoying the foot spa during the visit. Ashlea Court DS0000057246.V295921.R01.S.doc Version 5.2 Page 14 Residents’ social and psychological needs were identified in separate care plans; advice was given to ensure that the plans more clearly evidenced how the individual needs were being met. Residents’ religious needs were identified and they had the opportunity to access local churches or attend services held in the home. Staff told the inspector how a memorial service had been held in the home following the death of one of the service user’s relatives. One service user wrote in her survey “I feel that I am listened to and that the staff take notice of me” Other service users told the inspectors that they were able to exercise choice in aspects of their life and daily routines; that family and friends were made to feel very welcome when visiting the home. There was open visiting, the inspector observed a number of visitors to the home during the visit who made use of the communal and private areas of the home; there was positive interaction between staff and visitors, it was clear that staff endeavoured to build positive relationships and communication was good. The standard of the meal provision in the home remains very good. There was evidence that the choice of meals was always an agenda item at the residents meetings and all individual choices and preferences were accommodated where possible. Weekly menus are provided and the daily menu choice is posted throughout the home. The inspectors sampled a sandwich snack during the lunch; positive comments were received from all the service users spoken to about the cooked meal provided. During the meal one of the service users commented about the tea menu and said how fed up he got with all the sandwiches; however from discussions with the staff and inspection of the food records it was clear that cooked snacks and salads are regularly provided and many of the residents enjoy these meals. One of the residents had written on the survey how much she enjoyed jam sandwiches and the cook made these for her regularly. Staff were observed assisting residents; they demonstrated a very kind and patient manner and had a good knowledge of residents food preferences especially around the portion size. All areas of the kitchen seen were clean, tidy and well managed. A new dishwasher had been provided recently which the kitchen staff reported was working very well and had freed up more of their time to spend on a varied food preparation. The cook demonstrated a good knowledge of the required hygiene procedures and the nutritional needs of older persons. Ashlea Court DS0000057246.V295921.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are confident that their concerns will be listened to however documentation and recording of complaints needs to improve to demonstrate that the home takes complaints seriously and issues are investigated appropriately. Procedures are in place to ensure a proper response to any suspicion or allegation of abuse. EVIDENCE: A complaints procedure was displayed in the entrance hall. Service users and staff reported understanding of the procedure. All service users and visitors spoken to confirmed that they felt confident in raising issues with the staff or manager. The documentation to support complaint management had not improved since the previous visit; the home had received five concerns in the last six months however the records were found to be minimal and did not fully describe the management action taken with regard to any investigation or outcome in the form of action taken to resolve the issues and feedback to the complainant. Discussions with the manager confirmed that they considered that they had taken the issues seriously and the areas of concern had been addressed and passed on to the staff. Ashlea Court DS0000057246.V295921.R01.S.doc Version 5.2 Page 16 A procedure for responding to allegations of abuse was available and training records showed staff had been provided with adult abuse training. When asked about abuse, what it was and what they would do if they saw a service user being abused, the staff answered correctly. Staff interviewed also had a good knowledge of whistle blowing procedures. Recruitment practises remain robust; staff records evidenced that new staff had not commenced work prior to satisfactory police checks and references being in place. The management of the home had taken the decision following consultation with the Commission to re- employ a staff member who had received convictions for an offence. The relevant police checks had been repeated and risk assessments carried out to support the decision. The manager confirmed that the staff member had settled back into her role very well and there had been no issues with staff or residents regarding her employment at the home. Ashlea Court DS0000057246.V295921.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,22 and 26. Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. The standard of the environment in this home remains high, providing service users with a very safe, comfortable and homely place to live. EVIDENCE: The home provides and maintains very comfortable and safe facilities. All areas of the home are decorated and furbished to a high standard. There is a maintenance programme in place; new carpets had been provided to the ground floor sitting rooms and corridors. All areas were seen to be very clean and tidy; residents told the inspector during the visit and had written on surveys that the home was always kept very clean. Discussions were held with the manager around the over utilisation of the reception area and under usage of one of the main sitting rooms in the extension; the manager confirmed that although staff regularly encouraged residents to use the sitting room it was clear that many residents really Ashlea Court DS0000057246.V295921.R01.S.doc Version 5.2 Page 18 enjoyed sitting in the reception area as they could see everyone coming and going. There was good evidence that equipment provision in the home is regularly reviewed; six pressure relieving mattresses and further moving/ handling equipment such as slide sheets had recently been provided. Staff had also been trialing different types of hoists as the home intends purchasing a new mobile hoist to increase provision in this area from three to four. Ashlea Court DS0000057246.V295921.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 The quality outcomes in this area are good. This judgement has been made from evidence gathered both during and before the visit to this service. The home provides sufficient numbers of staff on each shift to meet the care needs of service users; staff are trained and competent to carry out their work. Recruitment practices afford sufficient protection for service users. EVIDENCE: The home was currently providing care for eleven service users with nursing care needs and thirty three with residential care needs; twenty one service users had identified low dependency care needs. From examination of the staff rosters, levels of seven care staff in the a.m. and six care staff in the p.m. were being maintained, with a number of morning shifts eight staff were rostered. Issues regarding staff sickness were continuing to be managed more effectively by the manager with positive results; the home also operates a pay incentive for staff who work all their shifts and for covering shifts at short notice. Staff at interview considered the staffing arrangements and levels to be satisfactory. All service users spoken to commented that they considered the staff had time to provide care in a timely fashion and did not feel they were unduly rushed or had to wait too long for their needs to be met. They also commented on how kind and supportive the staff were, one resident wrote in her survey “The staff are most obliging- the girls are lovely”. Ashlea Court DS0000057246.V295921.R01.S.doc Version 5.2 Page 20 Improvements had been made to the provision of staff training since the last visit; statutory training in fire- safety, moving/ handling, first aid and food hygiene was now on target. General courses on adult protection, infection control and risk assessment had been provided along with service specific courses on arthritis, Parkinson’s disease, Percutaneous Endoscopic Gastrostomy feeding and palliative care. The home had now exceeded the target of ensuring at least 50 of care staff had achieved National Vocational Qualification at level 2. There had been some gaps in the induction training programme which complies with National Training Organisation standards due to the recent absence of the training coordinator; the manager confirmed that this was in hand. Five staff files were examined; they were found to be in good order, they all contained the relevant documentation to comply with Schedule 2 of the Care Standards. Files of recently recruited staff demonstrated that the staff had commenced work in the home after the relevant police checks and references had been obtained. The home maintains records to support equal opportunities in their recruitment practices. Ashlea Court DS0000057246.V295921.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,36 and 38 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Although the manager has continued to make some improvements towards her management of the administration systems efforts must now be made to fully implement the staff supervision programme and formalise the quality assurance programme to demonstrate effective management of the home; however service users were satisfied that they lived in a home that was well managed and they were provided with appropriate opportunities. EVIDENCE: Service users and staff were very complimentary about the management and how the home was run. All the service users spoken to commented on how friendly and supportive the management team in the home were. Staff Ashlea Court DS0000057246.V295921.R01.S.doc Version 5.2 Page 22 confirmed that moral was good and commented that there was a good team approach to the care delivery at the home. Evidence from staff interviews and staff surveys indicated that the staff consider the manager and administrator to be very approachable, they take all issues raised seriously and prompt action to resolve matters. Staff and service user meetings were held regularly; there was evidence that requests and suggestions made at these meetings were discussed and actioned where possible. There was good evidence to demonstrate that the manager continues to focus on improving and maintaining the management systems in the home, specifically care documentation, staff training, recruitment practises, supervision and staffing. It is clear that the manager has been able to protect her management time more and has delegated relevant responsibilities to the qualified and senior care staff; she has a good understanding of the outstanding work now needed and intends to get to grips fully implementing and maintaining systems such as the care documentation, quality and supervision programmes over the next few months. The manager has not yet finished all the units of her National Vocational Qualification level 4 in management to gain the Registered Manager’s Award. Some further improvements had been made to the implementation of the staff supervision programme however there remained inconsistencies in that some staff had accessed regular sessions and others had not accessed any other than their appraisal. The manager had amended the format of the supervision document in line with advice given at the previous visit; records evidenced that the sessions covered all areas set out in the standards. Some further improvements had been made to the development of the quality assurance programme; audits of areas such as accidents, care programmes and facilities are regularly carried out, these need to have action plans in place where deficiencies are identified. Resident surveys have been carried out and the findings analysed on computer graphs; deficiencies identified need to have action plans in place. Stakeholders to the service should also be surveyed. The home needs to develop an annual development plan to support the quality programme. Advice from the previous inspection to provide more detailed records of further action taken to reduce accident reoccurrence had not yet been put in place. Records evidenced that service checks had been completed for all installations and equipment. The maintenance man completes regular checks on equipment and systems such as fire safety checks, bed rails and hot water; these records were seen and found to be satisfactory. Staff had last accessed a fire safety drill in March 2006. Environmental risk assessments were in place. Ashlea Court DS0000057246.V295921.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 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 4 X X 3 X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X 2 X 3 Ashlea Court DS0000057246.V295921.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 OP33 Regulation 24 Requirement The registered person must fully implement a formal structured quality assurance programme based on a systematic cycle of planning action and review, which is supported, by an annual development plan. Timescale of 31/03/06 not met Timescale for action 31/08/06 2. OP36 18(2) The registered person must 31/07/06 ensure that all staff including herself,receive regular documented supervision and that care staff receive at least six sessions per year. Timescale of 15/02/06 not met The registered person must ensure that records are clearly maintained of all complaints investigations, outcomes and contact with the complainant. Timescale of 16/12/05 not met. The registered person must make sure that the care documentation is maintained effectively and evaluated monthly. DS0000057246.V295921.R01.S.doc 3. OP16 22 30/06/06 4. OP7 15 (2) 15/07/06 Ashlea Court Version 5.2 Page 25 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. Refer to Standard OP31 OP38 Good Practice Recommendations The registered manager should hold NVQ level 4 or equivalent in Management and Care. The registered manager should review the accident audit records to include details of staff action to further reduce risk, especially with regard to falls. The registered manager should review the current procedures to support the medication systems to ensure they are more comprehensive in their methodology and reflect current updated practise. Records to support the receipt and returns of medication should be clearer and more detailed. 3. OP9 Ashlea Court DS0000057246.V295921.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Court DS0000057246.V295921.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. 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. 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