Inspection on 04/05/07 for Ashlea Court

This inspection was carried out on 4th May 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

Ashlea Court 21/01/09

Ashlea Court 16/05/06

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 Key Unannounced Inspection 4th May 2007 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.V339011.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.V339011.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) ashleacourt.gr@btconnect.com 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.V339011.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th May 2006 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: £420- £560. 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.V339011.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. • • This key inspection visit was unannounced and lasted from 9 a.m. until 6.30 p.m. The inspector spent some time chatting to twelve residents and ten relatives. Six staff, two visiting district nurses, the manager and administrator also talked to the inspector. Records about the care provided, and other records about the running of the home were looked at. Questionnaires about the home were sent to thirty of the residents, twenty staff, twenty relatives and five healthcare professionals involved in supporting residents. Twenty-three of the resident’s questionnaires, ten relative, two health care professional and sixteen of the staff ones were returned at the time this report was written. The inspector observed how staff and service users worked together throughout the day. People’s views about the home and what was found during the visit have been used to write the report and make judgements about the quality of care. Looked at events within the home since the last inspection. • • • • • 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. 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. Residents liked the food provided, are well fed and encouraged to eat a healthy diet. There were good visiting arrangements and visitors were made to feel very welcome, discussions with a number of relatives confirmed this. Ashlea Court DS0000057246.V339011.R01.S.doc Version 5.2 Page 6 Proper recruitment checks were made before new staff start in the home to ensure they are safe to work there. What has improved since the last inspection? What they could do better: Hot water temperatures in the home are checked regularly but when records show that the temperatures are too high work must be carried out to reduce them to safe limits, which will better ensure the resident’s safety. All the staff are receiving one to one supervision from their manager but this is not happening as often as it needs to. Staff must be provided with more regular, formal support to ensure they are provided with the appropriate guidance and leadership they need and to receive management feedback on their performance. Some residents felt that the home did not provide the range of activities and outings that they used to. Many of the policies and procedures now require review and development to ensure that the staff have the required information to support all their current working practises which would better promote and protect the resident’s safety and welfare. Ashlea Court DS0000057246.V339011.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. The summary of this inspection report can be made available in other formats on request. Ashlea Court DS0000057246.V339011.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.V339011.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5 and 6 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users and their relatives are provided with sufficient information to help them decide if the home is right for them. The admission process is thorough with staff ensuring that new residents feel welcome and secure. EVIDENCE: The service user guide and statement of purpose documents had been updated to provide prospective new service users and their families with current information about the service. Ashlea Court DS0000057246.V339011.R01.S.doc Version 5.2 Page 10 The inspector case tracked three resident’s care files which demonstrated that the format of the homes needs assessment covers all required areas; copies of completed assessments were detailed and appropriate. Copies of the Local Authority assessment and care plans are obtained prior to admission for those residents referred through the local Social Services care management teams. In addition to the pre admission assessment the home undertakes a further assessment of strengths and needs once the resident has arrived. It is on the basis of both these assessments that the residents plan of care is formalised. The written contract/statement of terms and conditions documents were agreed with residents and held on file. Copies of the letter written to potential service users following the manager’s assessment visits to confirm that the home can meet their needs were also held on file. Residents 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. The inspector spoke to two visitors looking around the home on their relatives’ behalf; they said that they were impressed by the friendliness of the staff and the facilities; they particularly liked the entrance hall area where residents could sit and watch everyone coming and going. A survey received from relatives detailed that they had completed research, visited other homes and chosen Ashlea Court on the basis of this. Staff spoken to confirmed that they were always informed of new residents care needs and specific equipment was provided prior to admission where possible. Visiting relatives were happy with the care being provided. There was good evidence to demonstrate that care staff were accessing a 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. The home does not provide intermediate care support. Ashlea Court DS0000057246.V339011.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s health and personal care needs are well met and take account of the resident’s needs and preferences. The medication systems are well managed ensuring the safety and welfare of the residents. EVIDENCE: Case tracking of three residents users was completed, which included examination of care records and discussions with residents and staff. Care programmes for one existing resident and two more recent admissions were looked at. The format of the documentation remains the same and the care plans were well developed; the documentation system was well maintained, Ashlea Court DS0000057246.V339011.R01.S.doc Version 5.2 Page 12 improvements had been made to ensure greater consistency and no gaps were identified during case tracking. Detailed individualised plans had been developed from the assessments; there was good evidence that the plans had been updated when changes in need had occurred. Risk assessments were in place for tissue viability, moving/ handling, nutrition and falls; these had been reviewed regularly and all high-risk areas had associated care programmes in place. The quality of the evaluation records was good with evidence of formal review meetings taking place. There was good evidence that the home sought support from the health care professionals such as Community Psychiatric Nurses, dieticians and District nurses when necessary. During the inspection the inspector spoke to two of the District Nurses who regularly visit the home; they confirmed that the communication was good, staff were always very helpful and she had observed that they demonstrated a very caring and supportive attitude towards the residents. One of the district nurses did raise a concern around one service user’s moving and handling needs which the manager was aware of and was following up with the service user’s General Practioner. Surveys completed by health care professionals were positive, the wheelchair therapist wrote, “ The home has worked with our team to learn about the equipment we can supply and have been willing to use some very complex equipment to give their residents an improved quality of life” Analysis of the surveys received from the residents and relatives together with discussions during the visit identified that everyone was very satisfied with the quality of care provided at the home and the attitude of the staff; no negative comments were received. Comments included “ I have been very impressed with the carers at Ashlea Court, I have appreciated their kindness and concern towards my relative and myself” and “The entire staff are most cheerful, helpful and informative and work as a team, this creates a lovely atmosphere.” Medication systems were examined; policies and procedures were in place which covered all areas of management however some of them are limited 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. There was evidence that the staff are proactive in ensuring that service user’s medication is reviewed by the G.P. Temperature recordings of the medication storage room and refrigerator are taken daily which were satisfactory. There was evidence that service users are supported to self – administer their medications; risk assessments were used to support the practise. Ashlea Court DS0000057246.V339011.R01.S.doc Version 5.2 Page 13 Storage of all medications was found to be satisfactory. Transcribing and medication administration records were completed satisfactorily. Records of receipt and returns of medication were in place. A number of the qualified and senior care staff have accessed the accredited medication courses. Ashlea Court DS0000057246.V339011.R01.S.doc Version 5.2 Page 14 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 and 15. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The arrangements for providing meals, visiting and supporting residents to make choices met with the expectations of the residents although some felt that the amount of arranged activities and trips out had fallen in recent times. EVIDENCE: Observation during the site visit indicated that the home operates very flexible routines, these include the time the service users get up, go to bed, where they eat their meals and how they spend their time. Residents and visitors were very happy with the visiting arrangements and it was clear that residents are supported to keep in touch with friends and family. The inspector observed a large number of visitors to the home throughout the day, all relatives spoken to said that the staff were very welcoming and supported their visits. Many of the residents access trips out with their friends Ashlea Court DS0000057246.V339011.R01.S.doc Version 5.2 Page 15 and family; one resident’s relatives from Canada were visiting for the week and she had accompanied her relatives on all their visits to see the extended family. Residents are supported to use the local village amenities such as shops, library, public houses and the church. One resident told the inspector how she likes to go and collect her newspaper from the village shop each morning. Although regular activities such as quizzes, dominoes, yoga, visiting entertainers and a pianist continue to take place, evidence from discussions with residents and comments on surveys identified some dissatisfaction with the current activity programme and lack of organised trips. One resident wrote, ”There are not so many activities as there used to be e.g. Easter Bonnet parade and painting etc.” The activity co-ordinator told the inspector that she felt a lot of the current residents were reluctant to participate in a formal activity programme which was why she had let this slip however records and discussions confirmed that the one-to one sessions with the residents had been well maintained. One of the residents was observed having a game of cards with the activity organiser, he told the inspector how much he enjoyed his regular games of Brag. Also during the visit a number of the residents were enjoying a reminiscence session looking at a variety of photographs and kitchenalia provided by a local organisation. The activity co-ordinator has developed and maintained separate social and psychological plans of care; given the current dissatisfaction with some aspects of the programme, advice was given to revisit the assessments and identify residents currents social needs and preferences which would inform the coordinator on what to include in the new programme. Resident’s religious needs were detailed in the care plans; residents are supported to visit the local church or attend a regular ecumenical service in the home. The manager told the inspector how she had recently arranged for an Icelandic priest to visit a resident of that nationality which had greatly supported the resident’s end of life care. The standard of the meal provision in the home remains very good, all comments received during the visit and from surveys were very positive. 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 meal served during the visit looked tasty and well presented. The majority of residents use the dining room and the mealtime was seen to be a relaxed Ashlea Court DS0000057246.V339011.R01.S.doc Version 5.2 Page 16 and social occasion with the staff interacting well with the residents; individual support was provided patiently and discreetly. The kitchen assistant or cook visits the residents daily to discuss menu choices; the staff demonstrated a good knowledge of the individual residents’ nutritional needs and preferences. A number of specialist diets were being provided and many residents were receiving “fortified” diets; resident’s weights are monitored regularly and any concerns are referred to community health services for support. The kitchen areas appeared clean, tidy and well managed. Ashlea Court DS0000057246.V339011.R01.S.doc Version 5.2 Page 17 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 and 18. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents knew who to complain to and were confident that this would be taken seriously. 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. Resident’s said that they knew who to complain to and were confident that any issues would be taken seriously. They felt assured that there would be no repercussions if they did complain. The home had received one complaint in the last twelve months, which had been substantiated. Records evidenced that the issues had been thoroughly investigated and appropriate action taken; records of staff meeting minutes identified that the issue had been followed up. Ashlea Court DS0000057246.V339011.R01.S.doc Version 5.2 Page 18 There were clear improvements in the management of complaints; the inspector noted that a number of concerns raised to the management had also been formally documented and followed up, which was very positive. The commission had not received any complaints about the home since the previous inspection visit. A procedure for responding to allegations of abuse was available and training records showed staff had been provided with training in safeguarding adults. When asked about abuse, what it was and what they would do if they saw a resident 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. Ashlea Court DS0000057246.V339011.R01.S.doc Version 5.2 Page 19 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): 19,22 and 26. People who use this service experience excellent outcomes in this area. This judgement has been made using available evidence including a 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; redecoration and refurbishment is carried out where needed. Ashlea Court DS0000057246.V339011.R01.S.doc Version 5.2 Page 20 The communal areas were all well utilised during the visit; residents commented on how happy and settled they were at the home. All areas seen were clean and tidy, there were no odour issues identified. All residents spoken to confirmed that they liked their rooms and the staff kept them clean and tidy. The exterior of the home is well maintained and all garden areas were tidy. The laundry room is sited at the rear of the home; this area was visited and appeared adequately equipped and well managed. Staff at interview confirmed a good understanding of infection control measures and confirmed adequate supplies of protective clothing. Equipment provision was discussed with the staff; they felt that a number of the residents would benefit from a “Stand Aid” type of hoist which continues to promote the residents independence yet safely meet their moving and handling needs; the manager confirmed that she was looking to purchase this type of hoist. Ashlea Court DS0000057246.V339011.R01.S.doc Version 5.2 Page 21 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 and 30 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are cared for by a group of staff who demonstrate a very caring manner and provide a very good standard of care but a number of residents felt at times that they had to wait too long for assistance. Staff are well trained, better supervised and competent to carry out their work. Recruitment practices afford sufficient protection for residents. EVIDENCE: The home was fully occupied at the time of the visit providing care for 48 residents; eighteen of these had identified nursing needs. From examination of the staff rotas, levels of seven care staff in the a.m. and six care staff in the p.m. were being maintained, although a number of morning shifts eight staff were rostered. There is a qualified nurse on each shift; a full time care co-ordinator has also been appointed who works in a supernumery capacity. Ashlea Court DS0000057246.V339011.R01.S.doc Version 5.2 Page 22 Staff sickness continues to be managed more robustly with staff incentives in place and the management taking disciplinary action where appropriate. Examination of records and discussions with the manager evidenced that on a number of weekends shifts there had been some staff shortages due to short notice absence, however this had improved in recent weeks; there was good evidence that the home had covered shifts where possible and utilised agency staff when available. Evidence from surveys and discussions with residents during the visit confirmed that they were satisfied that the care they received met their needs and how kind and supportive the staff were. A number of residents told the inspector during the visit and wrote in their surveys that the staff were very busy, and they felt that they had to wait some time for their call bells to be answered. Given that dependency levels during the visit appeared stable and not overwhelming for staff; that there were no current service users with complex needs and the staffing levels had been increased since the previous inspection visit the inspector advised that the work practices on the shifts been more closely monitored to ensure effective allocation and supervision is taking place. The home provides a good varied training programme for staff; the manager had an overview of the training completed by the staff and a current staff training and development programme in place. The home has changed their induction programme to incorporate the new common induction standards as developed by Skills for Care. Mandatory courses in moving/ handling, fire prevention, food hygiene and first aid were seen to be up to date. There was good evidence that the staff regularly accessed general and service specific courses; staff were due to attend courses on falls prevention, diabetes, strokes, palliative care and chronic obstructive pulmonary disease. The nursing staff access regular training courses and update sessions; since the last inspection courses on palliative care, pain control, use of the syringe driver and venupuncture have been accessed. Staff told the inspector that the home provided a very good training programme. The home remains committed to providing National Vocational Qualification training for staff with 52 of care staff now trained at level 2 or above; which is a positive achievement. The activity co-ordinator had recently completed the NVQ level 4 in care. Employment records for four staff appointed since the last inspection were examined. This showed that all workers had Protection of Vulnerable Adult register checks (Pova 1st) or Criminal Records Bureau check (CRB police check) in place prior to commencing employment and that they all contained the relevant documentation to comply with Schedule 2 of the Care Home Regulations. Ashlea Court DS0000057246.V339011.R01.S.doc Version 5.2 Page 23 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): 31,32,33,35,36 and 38. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The residents were satisfied that they lived in a home that was well managed and they were provided with appropriate opportunities. Resident’s safety is generally well promoted and protected. EVIDENCE: Residents and staff were very complimentary about the management and how the home was run. All the residents spoken to commented on how friendly and supportive the management team in the home were. Comments on the Ashlea Court DS0000057246.V339011.R01.S.doc Version 5.2 Page 24 surveys received from residents and relatives included “The staff and management are extremely kind and caring, I can’t thank or speak highly enough of the care they provide for my mum” and “This is a very well run home with a very happy family atmosphere among the staff and residents”. Staff 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. The manager has recently completed the NVQ level 4 qualification in management which supports the registered managers award she had already attained. It was clear at this visit that the manager and administrator have made improvements with a number of the management and administration systems with positive results. Improvements have been made in further developing and implementing a formal quality assurance programme; standards have been produced for key areas of service in the home, regular audits and surveys have been carried out in these key areas which have been analysed and where deficiencies have been identified, action plans have been drawn up. The results of the audits and surveys have been published in graph form on a notice board for residents and visitors to see. Advice was given to formally revisit the action plans to demonstrate where improvements have been made. So far surveys have been issued to residents and families however the next surveys are to target health care professionals who support the service. The home has produced an annual development plan which identifies the quality areas of improvement from 2006 and clearly sets out the standards to be achieved in this year. The policies and procedures are reviewed annually, a number of the documents were found to be limited in the depth of information they gave and advice was given to review them ensuring that they clearly reflected current practices in the home and that they were updated to meet current legislation and good practice. There were accurate and up to date records relating to any personal allowances the home keeps on behalf of residents. Ashlea Court DS0000057246.V339011.R01.S.doc Version 5.2 Page 25 Improvements have been made to the staff supervision programme with staff having accessed more regular sessions however examination of a number of the records evidenced that not all the care staff had accessed the required amount of sessions (six) within twelve months. Examination of maintenance records identified that checks and certificates were in place for installations and equipment. The fire safety equipment, checks and risk assessment were all in place and up to date. The maintenance man completes regular checks of the hot water temperatures however in recent months a significant number of hot water outlets have recorded temperatures which exceed the maximum level and there are no records of any action taken at the time. The manager was made aware of this issue and confirmed she would ensure the hot water temperatures were more closely monitored and appropriate action taken to reduce the temperatures to safe limits. Improvements had been made to the recording of further action taken to reduce accident reoccurrence. Regular checks were carried out on bed rails and other equipment such as wheelchairs. Ashlea Court DS0000057246.V339011.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 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 3 3 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 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 3 3 3 X 3 2 X 2 Ashlea Court DS0000057246.V339011.R01.S.doc Version 5.2 Page 27 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP36 Regulation 18(2) Requirement Timescale for action 15/07/07 2. OP38 13(4) The registered person must 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 and 31/07/06 not met. The registered person must 31/05/07 ensure that hot water temperatures at outlets accessible to residents do not exceed 43ºC. Ashlea Court DS0000057246.V339011.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP33 Good Practice Recommendations The registered person should review all the homes policies and procedures to ensure they are comprehensive, comply with current legislation and demonstrate current good practice. The registered person should ensure that the residents are consulted about the reintroduction of a formal activity programme which will meet their current social needs and preferences. The registered person should review work allocation and supervision/ monitoring practices for the care staff to ensure effective workload management on each shift to meet the care needs of the residents. 2. OP12 3. OP27 Ashlea Court DS0000057246.V339011.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Ashlea Court DS0000057246.V339011.R01.S.doc Version 5.2 Page 30 - 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. 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