Inspection on 14/05/07 for Ashlea Court Residential Home

This inspection was carried out on 14th May 2007.

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

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

Other inspections for this house

Ashlea Court Residential Home 18/10/05

Ashlea Court Residential Home 19/06/05

Ashlea Court Residential Home 12/11/04

Ashlea Court Residential Home 27/05/04

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

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

CARE HOMES FOR OLDER PEOPLE Ashlea Court Residential Home Archer Road Farringdon Sunderland SR3 3DJ Lead Inspector Mr Lee Bennett 14 th, Key Unannounced Inspection 15 May 2007 and 22nd June 10:00 th 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 Residential Home DS0000034309.V338096.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 Residential Home DS0000034309.V338096.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashlea Court Residential Home Address Archer Road Farringdon Sunderland SR3 3DJ 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) 0191 5282526 0191 528 2532 Winnie Care Limited Ms Gillian Margaret Reed Care Home 40 Category(ies) of Dementia - over 65 years of age (22), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (1), Old age, not falling within any other category (28), Physical disability over 65 years of age (8), Sensory Impairment over 65 years of age (5) Ashlea Court Residential Home DS0000034309.V338096.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th October 2005 Brief Description of the Service: Ashlea Court is a care home, providing personal care for up to 40 older people, some of whom may have dementia related needs. Nursing care is not provided at the home, but District Nursing services can be arranged where necessary. It is a purpose built care home with accommodation provided over two floors, with level access throughout. Level access into the home is from the main car park to the front of the building. A lift provides access between the two floors of the home. There is a garden area in front of the home, which includes a paved seating area. The home is situated on the outskirts of Sunderland near to local public transport links. It is also situated near to a range of local facilities, including doctors surgery, shops, pubs and places of worship. The range of fees for April 2006 to end of March 2007 are £372.00 to £394.00 per week, dependant upon need and whether the is council or privately arranged. Ashlea Court Residential Home DS0000034309.V338096.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Before the visit: We looked at: • Information we have received since the last visit on 18th October 2005. • How the service dealt with any complaints & concerns since the last visit • Any changes to how the home is run The Visit: Unannounced visits were made on 14th and 15th May 2007. During the visit we: • talked with people who use the service, relatives, staff, the manager & visitors • observed life here • looked at information about the people who use the service & how well their needs are met • looked at other records which must be kept • checked that staff had the knowledge, skills & training to meet the needs of the people they care for • looked around the building/parts of the building to make sure it was clean, safe & comfortable • checked what improvements had been made since the last visit We told the manager/provider what we found. After the visit: We looked at • • The provider’s view of how well they care for people The views of people who use the service & their relatives, staff & other professionals in questionnaires What the service does well: Service users benefit from level access on both floors, and equipment and adaptations are available to help physically disabled and frail service users to get around the home. This can help make the service accessible for service users with diverse needs. Each bedroom had its own en-suite toilets and hand washbasin. Staff in the home work hard to meet service users’ needs, and have a good approach to people. Staff demonstrate a good understanding of service users needs, including those of people with dementia. On the whole they were Ashlea Court Residential Home DS0000034309.V338096.R01.S.doc Version 5.2 Page 6 observed to communicate well with people with dementia. They often use humour and touch to aid this. Staff were also seen to display kindness and understanding, and to encourage service users to drink regularly to keep a healthy fluid balance. Attractively presented and nutritious meals are provided, which service users commented on in a complimentary manner. Service users and their relatives said many good things about this home. Their comments included: • • • • “The meals are lovely here … lovely puddings.” “Everything’s fine … I’m happy.” “They’re all nice here, especially (staff name) and the management.” “The food’s good.” A relative also stated that the home does the following well: • • • General care Giving medication Liaising with hospitals/doctor What has improved since the last inspection? The registered manager, and their line manager have worked to address one of the previously identified requirements. There are plans to address a recommendation. They have: • • Improved privacy by providing blinds to en-suite toilets. Plans to replace a corridor carpet. They have also continued to introduce improvements in the way the home is managed. They have a plan of improvements that they intend to make, such as getting new furniture, some new carpets and re-decorating. This has so far included the replacement of worn out bedroom furnishings. The manager has sought the views of service users on changes to menus, and keeps them informed about other improvements in the home. What they could do better: This inspection has tended to highlight improvements and good practice at this home. However some areas for attention have been identified. These include: • The need for staff to make time to sit with service users at meal times when offering them help to eat their food. DS0000034309.V338096.R01.S.doc Version 5.2 Page 7 Ashlea Court Residential Home • • • The need for staff to move people more safely. This needs to be written down clearly in their care plans, and should involve a professional such as an Occupational Therapist. The garden area still needs to be made more accessible, safe and suitable for the needs of people with dementia. Those domestic staff who also provide care work need to be offered the chance to study for an NVQ in care. One service user commented on the lack of activities at the time of the inspection. They said to the inspector: • “You get fed up just sitting around.” Arrangements for covering the activity workers post and duties are therefore important in keeping people involved in meaningful activities. A relative made the following suggestions: • • • Laundry - They ruin woollens through steam pressing More concert type entertainment More opportunities for residents to drink water/juices…dehydration is a concern of mine as it increased mental confusion 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 Residential Home DS0000034309.V338096.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 Residential Home DS0000034309.V338096.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): Standards 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admissions process ensures that service users’ needs are assessed to a good standard prior to care being offered. This helps to ensure that service users are offered the right type of care at the home. Intermediate care is not provided at Ashlea Court. EVIDENCE: For all those service users recently admitted to the home a Care managers’ (Social Worker) assessments was received before care was offered to them. The home ‘s manager and senior carers also complete assessments, relating to social interests, areas of risk, diet, and so on. Following this a plan of care has been developed. This details what actions the staff have to take to meet these needs. After a person has moved here a review takes place after six weeks. Ashlea Court Residential Home DS0000034309.V338096.R01.S.doc Version 5.2 Page 10 This is to make sure everyone is happy with the arrangements made. This involves the service user, their social worker and other representatives. Care plans are, thereafter reviewed by senior member care staff on a regular basis. Should a reassessment of need be required, this is arranged with the relevant Social Services Department, as was found to be the case for another service user whose needs were specifically looked at. Ashlea Court Residential Home DS0000034309.V338096.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): Standards 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users’ care plans are in place, and generally reflect their observed needs to an adequate level. Some have been poorly updated, and contain out of date information. Effective care planning can offer guidance to care staff regarding care practice and ensure consistency where necessary. Service users’ health care needs are identified through assessment and observation, and areas such as pressure care and falls prevention are subject to adequate supervision and care practice. This can contribute to peoples remaining well and health, and for professional help to be got where necessary. Medication is administered, recorded and audited in a way that follows recognised good practice. The effective management of service users’ medication can help contribute to their general health and wellbeing. Staff, with some exceptions, undertake appropriate care practices that help to preserve service users’ privacy and dignity. Ashlea Court Residential Home DS0000034309.V338096.R01.S.doc Version 5.2 Page 12 EVIDENCE: Each service user (whose needs and experience of care was ‘case tracked’) has a plan of care in place. Each service user’s care file follows a standardised format, and a template file is available to act as a guide. A system whereby assessments are used to guide the development of care plans, which are then monitored, evaluated and reviewed has been developed for service users. Specific advice continues to be offered (through the inspection process) to the manager regarding individual care plans, such as those relating to pressure care and manual handling. Care plans are ‘person centred’ (that is they are written in a way that reflects each person’s unique needs). Monitoring of specific needs occurs by using monitoring charts (for continence, diabetes and falls) and through daily progress notes. Monthly reviews are also undertaken, nevertheless, several areas of need, as detailed in care plans, were out of date, or with assessments and care plans not undertaken or put in place. This includes aspects such as pressure care, diet and manual handling. These care plans must be updated to reflect service users current needs. This can then provide clear and effective guidance for staff, and help ensure service users needs are being appropriately met. For example, during the inspection a service user was being hoisted from their chair to a wheelchair by two members of staff. The staff did this without talking to this person, either to guide or to comfort them. This person was visibly uncomfortable while being transferred. By explaining what they are doing and talking to service users staff can be more able to preserve the dignity of service users and give them the respect they need. Both relevant training and clearer guidance and supervision is needed in this area. Medication is, in the vast majority of cases, handled and administered by senior care staff. Medication rounds take place during the morning, at lunchtime, at teatime and in the evening. A monitored dosage system (Nomad) is used, whereby the dispensing pharmacist supplies each service users’ medication within a tray. This contains a series of small boxes that correspond to the four medication rounds of the day, and the seven days of the week. Printed ‘medication administration records’ are also supplied by the pharmacist. The registered manager has also introduced a recording system for staff to document the amount of variable dose and ‘as and when required’ medication administered. This can help ensure that accurate auditing can be undertaken. A sample audit of medicine stocks held in the home was carried out, and concluded successfully. Ashlea Court Residential Home DS0000034309.V338096.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements to provide activities and occupation are adequate. A planned, structured and well delivered activities programme can contribute to a more interesting and stimulating lifestyle for service users. Service users are supported to maintain family and other contacts should they wish. This can help ensure they do not become socially isolated. Service users are actively encouraged by staff to a good degree in exercising choice and control over their lives. This can help promote their independence. Service users receive a, varied and well presented, choice based, menu. This can help promote their general health and wellbeing. The support to people who need help to feed is adequate, but fails to uphold their dignity. EVIDENCE: The home has employed a worker specifically to plan and coordinate activities for service users. However they were on extended leave at the time of the Ashlea Court Residential Home DS0000034309.V338096.R01.S.doc Version 5.2 Page 14 inspection. Therefore fewer activities were being offered, and a service user specifically commented about this to the inspector. A relative also commented: “I have already contacted CSCI about a previous lack of recreational activities. Things are not much improved.” Visitors regularly call to the home. Service user’s relatives and representatives indicated that they are welcomed in the home, and that they are able to visit their relative or friends in private. During the inspection several visitors called to the home and were made welcome by staff. The home has a variety of communal lounges available, should service users wish to meet people in private outside of their own room. Relatives are also encouraged to contribute to the care of the service user to whom they are related, and able to share meals in the home if they so wish. Meals are provided within two large dining areas, one on each floor. Some service users take meals within their own bedrooms. Service users are offered a range of choices for meal times and consultation has taken place with service users about a revised summer menu. Staff are attentive to service users’ requests, and provide support and prompts where necessary. The lunchtime meal was attractively presented and service users were very complimentary about the food provided. The current levels of staffing support at mealtimes means that individual staff are having to deal with a range of tasks at this time. This results in support given for those people who need help to eat their food is being regularly broken by staff having to do other tasks. Some service users were also being fed by staff who were standing over them, rather than sitting by their side. This type of practice does not promote the dignity of service users. Ashlea Court Residential Home DS0000034309.V338096.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A clear complaints procedure is available that is implemented to a good standard. This can allow service users’, and their relatives, confidence in the process, and provide opportunity for the management team to improve the service provided. The manager and staff have a good understanding of local adult protection procedures. This can help contribute to the protection of service users from abuse. EVIDENCE: Since the last inspection there have been no complaints referred directly to CSCI to investigate. Service users and relatives indicated that they were aware of the home’s complaints process. All of the service users questioned stated that they were aware of who to speak to if they were unhappy with their care, as were relatives. The homes own records indicate that 1 complaint has been received since the last inspection of the home. A copy of the record kept, including details of the outcome, is given to the complaint to let them know what has been done. This can keep the complainant informed about the action taken by the home to address their complaint. Ashlea Court Residential Home DS0000034309.V338096.R01.S.doc Version 5.2 Page 16 The host local authority (Sunderland) publishes clear safeguarding adults (adult protection) procedures, of which the registered manager and staff are aware. Staff receive training and guidance on safeguarding adults from the local authority, internally, and through their work to attain an NVQ award in care. Should they be necessary, referrals are made, and demonstrate that the manager and staff have a good awareness of these procedures. Ashlea Court Residential Home DS0000034309.V338096.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is clean, and well maintained. This can help promote a positive image for service users, and ensure they remain safe. External space poorly addresses the specific needs of people with dementia. This means that safe and ready access to external space and fresh air is limited. EVIDENCE: The service users rooms were clean and many contained furniture and possessions personal to the individual. New carpets have been fitted in some areas of the home. Ashlea Court Residential Home DS0000034309.V338096.R01.S.doc Version 5.2 Page 18 Service users own rooms have en-suite facilities. Some en-suites benefit from natural lighting, and windows have been frosted and now fitted with blinds to ensure the privacy of service users. Since the last inspection much of the bedroom furniture, such as wardrobes, chests of drawers and bedside tables have been replaced. As has been previously reported it is difficult for service users from upstairs to access the garden areas, either independently or with staff help. An galvanized metal fence has been erected over some of the garden, blocking a walkway to an adjoining home and detracting from the ascetics and safety of the existing gardens. Guidance information was sent to the home’s manager regarding current good practice in the design of gardens for people with dementia. This sort of improvement has yet to be implemented in any way here. Corridors and toilet / bathing facilities have been provided with grab rails, and other adaptations to enable access for service users who are disabled or who are physically frail. This can help ensure the service is accessible to service users with diverse needs, and promote the equality of people with a range of disabilities and needs. Ashlea Court Residential Home DS0000034309.V338096.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are no better than adequate in ensuring service users’ needs are being met, and the care provider has been poor in reviewing staffing levels to respond to emergency situations. The staff team benefits from a good level with care qualifications, which can help demonstrate that staff are competent. However this competency needs to be more consistently translated into care practices. Service users are protected by robust recruitment procedures, which are well understood and implemented. This can help ensure that unsuitable candidates do not gain employment in the home. Training is well planned and has highlighted where staff require broader and more frequent training opportunities. A range of appropriate training can contribute to staffs’ understanding of service users’ needs and ensure sufficient competence to undertake their job. EVIDENCE: There are five care staff deployed within the home during the daytime (08:00 to 22:00) one of whom acts in a senior capacity. One member of care staff Ashlea Court Residential Home DS0000034309.V338096.R01.S.doc Version 5.2 Page 20 commences duty at 07:00 to provide additional assistance to the night shift workers, who finish duty at 08:00. A worker employed specifically to plan and help undertake activities has been recruited to the home. They were on extended leave at the time of the inspection, and this post was not being covered. Following an incident in the home, CSCI made a requirement that staffing levels be reviewed to ensure that suitable and sufficient monitoring arrangements could be put in place for some service users. This requirement was not addressed by the owner due to their financial considerations. This meant that supervision arrangements had to be completed by the existing team at five-minute intervals. This also resulted in time being diverted away from staffs other duties. The manager receives an ‘enhanced’ Criminal Records Bureau disclosure prior to staff commencing duties. Protection of Vulnerable Adults List (POVA first) checks are also being received were necessary. Two references are always obtained prior to employment being offered. Staff recruitment practices are governed by a policy that aims to ensure equal opportunities practices are adhered to. Care staff have received training in fire safety and adult protection, food hygiene, manual handling, food hygiene, aging and disability, dementia care, first aid and medication during 2006. Several have undertaken a course of study to attain an NVQ award in care. Several care specific courses are planned for 2007, which includes training specific to diverse or minority care needs, and training on equality and diversity is planned for later this year. The manager has indicated that well over half of the care staff team have attained an NVQ qualification in care, at level 2 or higher. Those staff employed as domestics, who also provide ‘care’ shifts, should also be given the opportunity to attend this training. Ashlea Court Residential Home DS0000034309.V338096.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. External management support and oversight arrangements are effective and operate at a good level. This can help ensure that the service is run in the best interests of service users. Internal quality assurance systems have been developed to an adequate level, but with scope for further improvement. This can allow the views of service users, relatives and others to be sought and the internal quality management of the service to be progressed. Service users personal monies are managed in a good way to ensure the interests are well served. Ashlea Court Residential Home DS0000034309.V338096.R01.S.doc Version 5.2 Page 22 Risks to the health and safety of service users, visitors and staff are minimised in a generally adequate manner. EVIDENCE: The registered manager has compiled a quality assurance file, which incorporates the views of service users and their relatives. Service users also have the opportunity to express their view at meetings, by questionnaire, and in day to day conversations with staff and the manager. The home is overseen by an Area Manager. This person provides regular, professionally based support, oversight and supervision of the home. Monthly inspections of the home by this person are also being progressed, which includes a focus on the quality, practices and procedures operated within the home. This can contribute to an effective quality assurance and management system focusing on service processes and outcomes. The home is kept generally clear of hazards to the health and safety of service users, visitors and staff. Risks to service users are subject to periodic assessments, and staff receive training on health and safety related topics. However, some service users were observed to be lifted by staff using ‘controversial’ under-arm techniques, which are seen as poor practice. Each service user who needs to be manually transferred must have an individual plan in place for this, and the advice of an appropriately trained and competent person, such as an occupational therapist, must be sought by the home’s manager. Ashlea Court Residential Home DS0000034309.V338096.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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 2 X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Ashlea Court Residential Home DS0000034309.V338096.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15(2)(b and c) Requirement The registered manager must ensure that care planning and assessment information is up to date and sufficiently detailed to guide care and manual handling practice. This is a new requirement. The registered manager must ensure that those service users who need help with feeding are supported in a way that promotes their dignity. Staff need to be deployed in sufficient numbers to help achieve this. This is a new requirement. The registered manager must provide adequate facilities for those service users accommodated on the first floor of the care home to safely and freely access the gardens and grounds. The previous action plan dates for this unmet requirement were 24/7/05, 30/3/06 and 26/09/06. Ashlea Court Residential Home DS0000034309.V338096.R01.S.doc Version 5.2 Page 25 Timescale for action 26/09/07 2. OP10 12(4)(a) 26/08/07 3. OP20 23(2)(o) 26/09/07 4. OP10 OP38 12(4)(a) The registered manager must ensure that staff provide appropriate levels of support, comfort and explanation for service users when undertaking manual handling tasks. This is a new requirement. 26/08/07 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 OP19 OP28 Good Practice Recommendations The registered person should arrange for the carpet in the service area, along to the dining room to be replaced. The registered manager should provide all staff who undertake personal care (including those domestic staff who work care shifts) the opportunity to undertake an NVQ level 2 in care. Ashlea Court Residential Home DS0000034309.V338096.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South Shields Area Office 4th Floor St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Residential Home DS0000034309.V338096.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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