Inspection on 19/06/05 for Ashlea Court Residential Home

This inspection was carried out on 19th June 2005.

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

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

Other inspections for this house

Ashlea Court Residential Home 14/05/07

Ashlea Court Residential Home 18/10/05

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 Key Unannounced Inspection 09:30 19 and 20th June 2006 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.V299113.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.V299113.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 (1), Dementia - over 65 years of age registration, with number (22), Old age, not falling within any other of places category (28), Physical disability over 65 years of age (8), Sensory Impairment over 65 years of age (5) Ashlea Court Residential Home DS0000034309.V299113.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The one specific service user in the DE category will relate to the current service user only. Staff must receive suitable training regarding the needs of service users with early onset dementia within two weeks of the service users admission. Staff must receive suitable training regarding the needs of service users with early onset dementia within two weeks of the service user’s admission to the home. 18th October 2005 Date of last inspection 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, 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. 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 £346.00 to £361.00 per week, dependant upon need. Ashlea Court Residential Home DS0000034309.V299113.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over two days in June 2006 and was a scheduled unannounced inspection. The inspection included a separate look at the pre-inspection questionnaire (completed by the manager), and comment cards received from service users and their relatives. The care experienced by a sample of service users was ‘case tracked’. This is where their views are sought, their care needs examined, and the care they receive is inspected. A tour of the building also took place, and a sample of staffing and service users’ records was inspected. Service users, staff, the registered manager and visitors were spoken with, and the inspector took a meal with service users on the ground floor. The judgements made are based on the evidence available to the inspector during the inspection, the pre-inspection questionnaire supplied by the registered manager and the comment cards completed by service users. There were no comment cards completed or returned by relatives. Judgements relating to the management of service users savings are based on evidence provided centrally by Winnie Care, and meetings held with the registered person and information supplied by them. What the service does well: Staff were observed to have a good rapport with service users, and to make visitors welcome. Service users comments included: • • • • • • “I enjoy living at Ashlea Court.” “Quite pleased with staff.” “Quite good support.” “I have settled down in my new home.” “John (the cook) is excellent.” “Gill (the manager) knows her job and is a nice lassie.” Information and advice is available to service users, and others involved in their care, to help them decide if this home can meet their needs and wishes. Relatives appear to be made welcome, and one regularly shares meals with his wife in the home. Service users made positive comments about the food provided, which was observed to be well presented, nutritious, and to include fresh fruit and vegetables, as well as fortified foods. Staff are available to provided 1 to 1 support where needed. Service users also benefit from purpose built accommodation that includes an en-suite toilet and hand washbasin. The home is effectively managed and has robust line management arrangements. Ashlea Court Residential Home DS0000034309.V299113.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ashlea Court Residential Home DS0000034309.V299113.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashlea Court Residential Home DS0000034309.V299113.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2, 3, 5 and 6. Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Service users are offered a good level of information about the home prior to their admission. This can help them to decide if the home is right for them. Each service user has an adequate written contract / statement of terms and conditions with the home, which provides information on the rights and obligations of both parties. This helps to ensure that service users and their representatives are clear about what they can expect from the home. The admissions process ensures that a good level of information regarding service users’ needs is obtained 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. Ashlea Court Residential Home DS0000034309.V299113.R01.S.doc Version 5.2 Page 9 EVIDENCE: Before moving to the home service users confirmed that they received information to decide if the home was suitable for them. This includes a service users’ guide. Service users are able to visit the home prior to their admission. The majority of service users moving to the home benefit from the help of a social worker in making this decision, and during the inspection the manager provided advice to a prospective service user to obtain this professional support. On admission to the home each service user is provided with a contract, outlining various terms and conditions regarding their occupancy within the home. All of those service users who completed a questionnaire stated that they had received this. Where a service user has been placed with the assistance of a local authority their residency is also determined by the detail of the contract between the local authority and the home. Should a person move to the home under a ‘private’ arrangement then they would be supplied with a standard form of contract between the home and service user only. Service users deemed as ‘self-funding’ by the local authority can still, if assessed by that authority, be placed under the local authority contract. For those service users most recently admitted to the home (whose placement and needs were case tracked – a method by which inspectors are required to look at the service provided at the home, by focusing specifically on individual service users experiences of care), a ‘Care Managers’/ social workers’ assessments was received before care was offered to them. Following this a plan of care was developed, and a review planned to take place after six weeks. This involves the service user, their social worker and other representatives. Care plans are, thereafter reviewed by a 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.V299113.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgment 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. Some gaps are evident. 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 assessment, planning, supervision and care practice. Care staff are good at seeking medical advice where it is needed. Medication storage and administered arrangements are adequate. The medication policy is in need of review. The effective management of service users’ medication can help contribute to their general health and wellbeing. Staff undertake appropriate care practices that help to preserve service users’ privacy and dignity. Ashlea Court Residential Home DS0000034309.V299113.R01.S.doc Version 5.2 Page 11 EVIDENCE: Each service user (whose needs and experience of care was ‘case tracked’) has a plan of care in place, and the manager and senior carers continue to undertaken revisions of these documents when service users needs change. Each service user’s care file follows a standardised format, and a template file has been developed 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 was offered (through the inspection process) to the manager regarding individual care plans, such as those relating to diabetes, mental health and pressure care. Such care plans need to accurately reflect assessed needs, and thereby provide the guidance necessary to ensure consistent care practice, and offer a mechanism to monitor service users’ needs and thereafter monitor and review their progress. Monitoring of specific needs occurs by using monitoring charts (for pressure relief, continence, diabetes and falls) and through daily progress notes. Highlighted risk areas, such as falls, are also care planned/risk assessed. Care plan reviews would benefit from more detail, and advice in this respect was offered to the manager at the time of the inspection. Personal and health care needs are outlined within service users’ assessments and care plans. Service users stated that in 9 out of 10 cases they ‘always’ receive the care and support they need. One person said they ‘usually’ do. All service users stated that they ‘always’ receive the medical support they need. This is supported by the notifications received from the care home, that indicate that if urgent medical advice or assistance is needed this is sought. Arrangements for ensuring service users privacy is upheld during care giving are in place, such as lockable bedrooms and WCs and bathing areas. Staff knock on doors before entering service users’ rooms. The management and administration of service users’ medication is governed by a set of policies and procedures, available to staff responsible for this task. These documents have been developed in a gradual way to respond to identified omissions, and past inspection requirements and recommendations relating to this and other homes. The care provider is developing revised procedures, the development of which will be monitored by CSCI. 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 Ashlea Court Residential Home DS0000034309.V299113.R01.S.doc Version 5.2 Page 12 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. An audit of the medication used by those service users who were case tracked was concluded successfully, and medication administrations are appropriately recorded. Ashlea Court Residential Home DS0000034309.V299113.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): Standards 12, 13, 14 and 15. Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Arrangements to provide activities and occupation have improved, are adequate, and have scope for further development within the home. The development of a planned, structured and well delivered activities programme can contribute to a more interesting and stimulating lifestyle for service users. Service users are able to maintain family and other contacts to a good degree 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 good, varied and well presented, choice based, menu. This can help promote their general health and wellbeing. Ashlea Court Residential Home DS0000034309.V299113.R01.S.doc Version 5.2 Page 14 EVIDENCE: The home has recently recruited a worker specifically to plan and coordinate activities for service users, and they have recently commenced duty. Activities are being carried out on a more frequent and more structured basis than in the past, and on the day of the inspection included a bowling game and bingo session. Visitors regularly call to the home and are able to visit their relative or friend in private and during the inspection several visitors called to the home. 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 lounge 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 complimentary about the food provided. Staffing support at mealtimes has been increased which allows support to be offered to service users and for difficult behaviours to be addressed and managed. Advice from a dietician has been sought regarding the home’s planned menus available in the home, and specifically to ensure these include adequate levels of vitamin D for those service users are unable to leave the home, and thereby do not receive adequate exposure to natural sunlight. Ashlea Court Residential Home DS0000034309.V299113.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): Standards 16 and 18. Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. A clear complaints procedure is available and is being fully implemented. This can allow service users’, and their relatives, confidence in the process, and provide opportunity for the management team to improve the service provided. Local adult protection procedures have been implemented and instigated to good effect to 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. The homes own records indicate that complaints have been acknowledged, responded to and resolved. The host local authority (Sunderland) publishes clear adult protection procedures, of which the registered manager and staff are aware. Staff receive training and guidance on adult protection from the local authority, internally, and through their work to attain an NVQ award in care. Ashlea Court Residential Home DS0000034309.V299113.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 23 and 26. Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. Service users have access to safe and comfortable indoor space. Access to outdoor space is dependant upon staffing support and has been poorly designed in respect of service users needs and safety. Service users’ bedrooms adequately suit their needs. This can enable sufficient space for manual handling tasks, and improved levels of privacy by access to individual en-suite facilities. The home is clean and adequately complained. A clean and well-maintained home can help promote a positive image for, and is respectful to service users. Ashlea Court Residential Home DS0000034309.V299113.R01.S.doc Version 5.2 Page 17 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. The corridor along from the service areas of the home, and along to the dining room is heavily marked and should be replaced. This is a recommendation of this report. Service users own rooms have en-suite facilities. Some en-suites benefit from natural lighting, and although windows have been frosted, they lack blinds to ensure the privacy of service users. These must be provided, and this is a requirement of this report. Much of the bedroom furniture, such as wardrobes, chests of drawers and bedside tables, were purchased when the home first opened. Several are worn and stained inside. These require replacement, and the care provider has plans to replace these. The majority of dining room chairs have now been replaced with those fitted with glide rails, which can help staff in meeting the needs of service users who require help to sit in at the dining tables. They can also promote independence by making it easier for service users to move these chairs. Some lounge chairs have been obtained, and more are now on order. Spare covers should be obtained to ensure cushions remain covered whilst laundering is being progressed. This will help ensure that whilst carers are being laundered, the dignity of service users and general appearance of the home is maintained. Corridors and WC / 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. Plans to redecorate the home are being developed, and the registered manager was advised to seek guidance and advice to ensure that décor schemes help to meet the needs of those service users with dementia or a visual impairment. This would further promote accessibility for people with diverse and varied needs. The home benefits from a large garden area at the front of the property, and a small area towards the rear. Service users who live on the first floor of the home may find it difficult to use this facility, and there is no means to safely and independently access this area without staff support. An area to the front of the home has been fenced off, but has not been designed with the needs and safety of service users in mind. The requirement relating to external space therefore remains. Guidance on needs related garden design has been supplied to the registered manager. Ashlea Court Residential Home DS0000034309.V299113.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Staffing levels are adequate to allow service users’ needs to be met. The staff team benefits from a good level with care qualifications, which can help ensure that a competent staff team is available to meet service users’ needs. Service users are protected by the home’s recruitment procedures, which are implemented to a good standard. This can help ensure that unsuitable candidates do not gain employment in the home. The way training is planned has improved to a good standard, which 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: For the 32 service users living in the home there are five care staff deployed within the home during the daytime (08:00 to 22:00). A worker employed specifically to plan and help undertake activities is also employed in the home. Ashlea Court Residential Home DS0000034309.V299113.R01.S.doc Version 5.2 Page 19 Should occupancy increase, staffing levels must be reviewed to ensure they remain adequate to meet service users needs and ensure their safety. Staff records indicate that the manager receives an ‘enhanced’ Criminal Records Bureau disclosure prior to staff commencing duties. ‘POVA first’ checks are also being received. 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, infection control, aging and disability, dementia care, first aid and medication during 2005. Several have undertaken a course of study to attain an NVQ award in care. Several care specific courses are planned for 2006, 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 50 of the care staff team have attained an NVQ qualification in care, at level 2 or higher. Ashlea Court Residential Home DS0000034309.V299113.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38. Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. External management support and oversight arrangements have been improved with the recruitment of an Area Manager. This operates at a good level, and 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. Centralised arrangements for the handling of service users’ personal savings have been reviewed to help ensure service users’ interests are better served. Risks to the health and safety of service users, visitors and staff are minimised in a good manner. Ashlea Court Residential Home DS0000034309.V299113.R01.S.doc Version 5.2 Page 21 EVIDENCE: The registered manager has compiled a quality assurance file, which incorporates the views of service users and their relatives. Periodic checks of other aspect of the service, such as the premises, care planning, medication, etc. are also undertaken. Since the last inspection an Area Manager has been recruited who is providing 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 clear of hazards to the health and safety of service users, visitors and staff, although one dining room chair was found to be loose and potentially dangerous. This was removed from this area at the time of the inspection, and an upstairs window that was not restricted also dealt with. Risks to service users are subject to periodic assessments, and staff receive training on health and safety related topics. The inspector offered some general health and safety advice, namely to improve the detail of audits, and by sampling different areas of the home. Ashlea Court Residential Home DS0000034309.V299113.R01.S.doc Version 5.2 Page 22 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 N/A 3 3 N/A 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 N/A DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 N/A 18 3 3 3 N/A N/A 3 N/A N/A 3 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 N/A 3 N/A 3 N/A N/A 3 Ashlea Court Residential Home DS0000034309.V299113.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO Ashlea Court Residential Home DS0000034309.V299113.R01.S.doc Version 5.2 Page 24 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 OP20 Regulation 23(2)(o) 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 requirement were 24/7/05 and 30/3/06. The registered manager must provide blind for service users en-suite areas to help ensure their privacy. This is a new requirement. Timescale for action 26/09/06 2. OP24 12(4)(a) 26/09/06 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 OP19 Good Practice Recommendations The registered person should arrange for the carpet in the service area, along to the dining room to be replaced. Ashlea Court Residential Home DS0000034309.V299113.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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. 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