Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 25/07/07 for Ashlee Care Home

Also see our care home review for Ashlee Care Home for more information

This inspection was carried out on 25th July 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Ashlee care home is a family run business and centres its care on residents needs and daily routines, which are flexible to ensure independence and choice, are maintained. This was demonstrated in the detailed records of care that were in place. Meals were home cooked with varied and residents reported that the meals were enjoyed.Ashlee Care HomeDS0000044372.V340494.R01.S.docVersion 5.2The home provides a comfortable environment for residents. Bedrooms demonstrated residents` individual tastes and were furnished with their own personal belongings. The relationship between staff and residents was observed to be positive and open. The provider/manager works in the home most days and supervises the care and services provided.

What has improved since the last inspection?

The new care planning systems in place were detailed, person centred and provided a good audit trail with which to base care reviews upon. The majority of the staff team have achieved a National Vocational Qualification (NVQ) in care at level 2, which demonstrates that residents are care for by trained staff. Screening has now been purchased for shared rooms to ensure residents privacy and dignity can be maintained when providing personal.

What the care home could do better:

The storage facilities available continue to be minimal however this should be resolved once the homes planned building work is undertaken. Access to the garden area remains unchanged as the ramp from the conservatory into the garden area is quite steep and not suitable for independent wheelchair users, again this should be resolved once the planned building work has been undertaken.

CARE HOMES FOR OLDER PEOPLE Ashlee Care Home 89 Nottingham Road Long Eaton Derbyshire NG10 2BU Lead Inspector Angela Kennedy Unannounced Inspection 25th July 2007 10:30 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 Ashlee Care Home DS0000044372.V340494.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. Ashlee Care Home DS0000044372.V340494.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashlee Care Home Address 89 Nottingham Road Long Eaton Derbyshire NG10 2BU 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) 0115 9721732 www.ashleecarehome.co.uk Mr Arjoon Rao Mahadoo Mr Arjoon Rao Mahadoo Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Ashlee Care Home DS0000044372.V340494.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Mr Arjoon Rao Mahadoo is registered to provide accommodation and person care for persons of both sexes whose primary needs fall within the following category, Older Persons not falling in any other category (OP). Within the maximum number of 21 service users, one person named in connection with an application processed in January 2007 may be admitted in the category of Dementia (over 65 years) DE (E). 24th April 2006 2. Date of last inspection Brief Description of the Service: Ashlee is a care home for twenty-one people aged 65 years and over. It is a detached house in a residential area of Long Eaton close to the town centre and local facilities. The home has seventeen single and two shared bedrooms, five single rooms have ensuite facilities. The home is on two floors accessed by stairs and a passenger lift. Residents have access to a garden area. The fees for residency at Ashlee at the time of this inspection ranged from £311 to £420 per week. Services not included in this fee were Hairdresser Private Dentistry Chiropody Cost varies dependent on service required Cost varies dependent on service required and items purchased £9 per visit Ashlee Care Home DS0000044372.V340494.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over approximately five hours. Key inspections take into account a wide range of information and commence before the site visit by examining previous reports and information such as any reported incidents. The site visit is used to see how the service is performing in practice and to meet with residents and their representatives. The inspection was focused on assessing compliance with defined key National Minimum Standards. The commission had requested the service to complete an Annual Quality Assurance Assessment and the information provided within this assessment has also been used within this inspection report. Care home surveys completed by residents and their representatives have also been used to inform this report. The Provider/ registered manager was present at the inspection and the registered manager’s son who is one of the company directors. Staff opinions were also sought to ascertain their views of the service and their opinion of the training and support provided to them. Two residents were case tracked. Case tracking is a method used to track the care of individuals from the assessments undertaken before they are admitted to a service through to the care and support they receive on a daily basis. This includes looking at care plans and other documents relating to that persons care, talking to staff regarding the care they provide, talking to the resident if they are able to communicate or observing the care they receive. Several other residents were also spoken with at this inspection visit and an external arts and crafts provider, who visited the residents at Ashlee on a regular basis. What the service does well: Ashlee care home is a family run business and centres its care on residents needs and daily routines, which are flexible to ensure independence and choice, are maintained. This was demonstrated in the detailed records of care that were in place. Meals were home cooked with varied and residents reported that the meals were enjoyed. Ashlee Care Home DS0000044372.V340494.R01.S.doc Version 5.2 Page 6 The home provides a comfortable environment for residents. Bedrooms demonstrated residents’ individual tastes and were furnished with their own personal belongings. The relationship between staff and residents was observed to be positive and open. The provider/manager works in the home most days and supervises the care and services provided. 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. The summary of this inspection report can be made available in other formats on request. Ashlee Care Home DS0000044372.V340494.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 Ashlee Care Home DS0000044372.V340494.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions to Ashlee are not made until a full needs assessment has been undertaken to ensure the service is confident that staff have the skills, ability and qualifications to meet the assessed needs of the prospective resident EVIDENCE: The written information provided by Ashlee prior to this inspection stated that: Ashlee had a detailed pre-admission assessment procedure which generally involves the manager going out to visit prospective residents in their homes or in hospital, if appropriate. The information obtained during these visits helps the manager and his senior care staff decide whether Ashlee can provide the Ashlee Care Home DS0000044372.V340494.R01.S.doc Version 5.2 Page 9 prospective service user with the care that they require before offering them a place. (Standard 3) On the day of this inspection: The pre admission assessments of the two residents case tracked were looked at. Both had assessments in place that had been undertaken prior to admission. These assessments addressed all areas of personal, health and social care needs. It was confirmed by the registered manager that for residents funded and assessed by the local authority, an assessment would also be undertaken by Ashlee prior to admission. Ashlee Care Home DS0000044372.V340494.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents health,personal and social care needs and how they are to be met are set out in their plan of care, with resident involvement and are reviewed regularly. The homes medication practices protect residents and residents were treated respectfully and their right to privacy maintained. EVIDENCE: The written information provided by Ashlee prior to this inspection stated that: Ashlee have a new care plan system, which has proven to be more efficient and effective in terms of determining and providing a resident with their specific care needs. The new format is clear and well presented and residents are involved in the creation and development of their plans. Ashlee Care Home DS0000044372.V340494.R01.S.doc Version 5.2 Page 11 The plans give staff clear instructions on how to administer specific care and they also provide detailed information on each resident, which enables the home to provide a tailor made service. Information such as personal preferences, i.e. likes and dislikes, preferred rising and going to bed times are all included. (Standard 7) The care planning system also incorporates risk assessments, which are constantly reviewed, and act as reminders to staff to monitor residents and ensure that the risks identified are eradicated or at the very least reduced to a minimum. The plans also incorporate monthly reviews, which ensure that for those residents where there has been no change a full evaluation of the care they require is undertaken every 4 weeks. (Standard 8) A comprehensive policy on the self-administration of medication is in place by, which is accompanied by a comprehensive risk assessment system that enables the management and senior staff to determine whether a resident is capable of self-administration of medication. (Standard 9) The management has purchased a mobile privacy screen which ensures the protection of residents privacy and dignity when carrying through personal care tasks in private. (Standard 10) On the day of inspection: Improvements were noted in care plans and risk assessments. The new care plan system that was discussed at the last inspection was now in place. This system incorporated care plans, assessments, medical information including medical history, prescribed medication and a record of all health care appointments. The needs and preferences of each individual were included and addressed areas such as physical and mental abilities, health and hygiene, food, drink and dietary requirements and preferences, and religion, cultural and social requirements and choices. The information provided for the two residents who were case tracked was detailed and clearly informed staff of the support each resident required in order for their needs to be met. Assessments in place included mental health, physical health, personal risk, behaviour, pressure sore assessment, nutrition and falls assessments. Care plans had been generated from these assessments and were reviewed each month by the registered manager and senior care staff. Evidence was in place that demonstrated that residents were involved in the formulation of their care plans. Ashlee Care Home DS0000044372.V340494.R01.S.doc Version 5.2 Page 12 On the day of inspection there were no residents living at the home that self administered their medication, however a risk assessment was in place for residents who in the future wished to self administer their medication which will assess the resident’s capacity to do so. Sufficient staff at the home had undertaken the required training in order for them to administer medication to residents . The homes procedures for the storage,administration and handling of medicines was examined and found to be satisafactory. During a tour of the building it was noted that a mobile privacy screen had been purchased for a shared room. This was a requirement from the last inspection, which has now been met. Residents spoken with on the day of inspection stated that they were happy with the care provided to them at Ashlee and confirmed that the staff team treated them with respect. Observations of staff interaction with residents appeared friendly and relaxed, with a positive rapport noted. Ashlee Care Home DS0000044372.V340494.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): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to exercise choice and control over their lives which promotes independence and the meals provided to the residents were enjoyed EVIDENCE: The written information provided by Ashlee prior to this inspection stated that: At Ashlee a number of social activities for residents are provided. This includes keep fit classes, Arts and Crafts sessions, Karaoke afternoons etc. In addition Ashlee is visited twice a month by Long Eaton Primary and Junior School, when the visiting school children play various games with residents ranging from cards to board games. Every Resident’s birthday is treated as a very special event and a celebratory birthday tea party is arranged for the individual whose birthday it is, this Ashlee Care Home DS0000044372.V340494.R01.S.doc Version 5.2 Page 14 includes cutting of the cake, exchange of gifts and singing birthday songs. Family, friends and representatives are always encouraged to attend. As part of the care planning process, all residents are asked prior to admission, what their likes and dislikes are and what activities they particularly enjoy. A concerted effort is made to enable the residents to continue to partake in their preferred activity should they wish to do so. (Standard 12) If, however, their chosen activity is slightly beyond the capability of the care home family members are encouraged to help the resident in continuing to partake in the activity which in turn encourages family/friends/representatives to maintain contact with the resident. (Standard 13) Whilst residents are encouraged to become involved in arranged social activities, the staff at Ashlee understands that residents have the right to choose whether they want to partake. In addition Residents are free to choose whether they wish to follow the homes general daily routine; should they choose not to then they are free to have their meals when they wish and get up or go to bed when they like. Freedom and the promotion of continued independence is the cornerstone of Ashlee Residential Care Homes ethos. (Standard 14) In addition to the care plans, daily diary and staff notice board, Ashlee has an annual planner which is located in the communal area, which illustrates all the activites arranged for the year. This information is duplicated on the homes general notice board. Furthemore when specific events are due to take place more prominent notices are designed and advertised throughout the home as reminders to residents and visitors. Ashlee has introduced a new more multicultural menu for residents; choices now include curry, Italian dishes, Chinese stir-fry. (Standard 15). Ashlee’s plans for improvement within next 12 months included, the consideration of the purchase of a 21 seater minibus, so that residents can be taken out during the summer months to places of interest. (Standard 12). On the day of inspection: Some of the residents were spoken with and confirmed that the activities mentioned above took place at Ashlee. In general it appeared that these activities were enjoyed but many of the residents spoken with expressed an interest in more community based activities, such as trips out and trips around the local community. This information was fed back to the registered manager who stated that residents were able to visit the local shops with staff support. Records were maintained within the daily diary of activities and trips out for individuals. Ashlee Care Home DS0000044372.V340494.R01.S.doc Version 5.2 Page 15 Arts and Crafts were provided by an external source on a fortnightly basis. As the person that provided arts and crafts was at Ashlee on the day of inspection, a discussion took place with them regarding the types of art work available and the general level of interest from resident. It was stated that seasonal craft work and card making was generally undertaken, although it appeared that the numbers of residents who chose to participate was often minimal in numbers of around three to four residents. However it was also stated that some residents chose not to participate but to observe the activities being undertaken. Of the residents spoken with, it was confirmed that they were able to meet with their visitors within their private accommodation or within the communal areas of the home as they so wished. There were no visitors to speak with at the time of the inspection. Residents relatives or their representatives managed their personal finances, on the day of inspection the majority of residents had a small amount of money in safe keeping at the home- please see standard 35 of the report regarding this. The menus were seen and demonstrated that two choices were provided at the main meal and a variety of sandwich choices were available at teatime and hot alternatives were also available. Residents spoken with were happy with the quality and choices of meals available at Ashlee. However none of the residents spoken with were able to confirm what the lunchtime choices were. It is therefore recommended that the daily meal choices be advertised in a prominent place for residents to see. The cook confirmed that discussions with residents had taken place the previous day regarding their preferred meal choices. Ashlee Care Home DS0000044372.V340494.R01.S.doc Version 5.2 Page 16 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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were confident that any concerns they had would be promptly addressed and the practices in place ensured residents were protected from abuse. EVIDENCE: The written information provided by Ashlee prior to this inspection stated that: Ashlee has a specific complaints procedure which is displayed in the home for all visitors, family members and residents to view. This information is also included in the homes Service users guide. In addition a record of all complaints is kept in the home. (Standard 16) Residents legal rights are protected via the homes contract of residence which contain the terms and conditions of the home whilst the service users guide and statement of purpose illustrates the service users rights. Residents are registered on the electoral roll and are given the opportunity to vote by post or by visiting the polling station should they wish to do so. (Standard 17) Ashlee has an extremely robust safeguarding adults procedure in place. The registered manager is also a fully qualified trainer and assessor in safeguarding Ashlee Care Home DS0000044372.V340494.R01.S.doc Version 5.2 Page 17 adults training and regularly trains the staff on safeguarding adults issues. (Standard 18). On the day of inspection: The complaints procedure was displayed in the entrance hall of Ashlee.No complaints had been received by Ashlee in the last 12 months. The commission had received one anonymous complaint in September 2006 which related to low staffing levels on two separate occassions. This complaint was returned to the registered manager/ provider for investigation. However the registered manager stated that he was not aware of this complaint and had not received information from the commission regarding this. The staffing levels seen on the day of inspection and on the weekly rotas were satisfactory in ensuring resident’s needs could be met. (See standards 27-30) Of the residents and staff spoken with, all said they felt the numbers of staff on duty were able to meet resident’s needs. Residents spoken with also stated that if they had any concerns they would speak to the manager or a member of staff and said they were confident that these would be dealt with. Ashlee had not received any Safeguarding Adults referrals or investigations in the last twelve months. The registered manager/ provider has undertaken specific training in Safeguarding Adults, which enables him to train the staff team in Safeguarding Adults practices and procedures. Staff were kept up to date in Safeguarding Adults practices, and training had taken place in March of this year with an additional session planned for October of this year for staff that had not undertaken the training in March. Ashlee Care Home DS0000044372.V340494.R01.S.doc Version 5.2 Page 18 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): 19,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a safe and well-maintained home, which ensures their safety and comfort, and once further planned developments are in place this will provide improved accessibility and security within the grounds of the home for residents. EVIDENCE: The written information provided by Ashlee prior to this inspection stated that: A safe and well maintained environment was provided with regular checks and updates carried out of fire risk assessments, fire prevention and fire fighting equipment. Furthermore, the manager and the homes handyman carry out a monthly Ashlee Care Home DS0000044372.V340494.R01.S.doc Version 5.2 Page 19 evaluation of the homes physical environment to ensure that the premises is kept well maintained at all times. (Standard 19) Ashlee provides comfortable indoor and outdoor communal facilities with a large conservatory which is a popular place for communal congregation especially during the summer months. (Standard 20) The home provides numerous toilet and bathing facilities with four assisted baths and one assisted shower. In addition five rooms have en-suite facilities, while all other rooms have sinks with hot and cold running water for personal use. (Standard 21) In addition to the assisted baths, the home also provides a mobile hoist for use with residents who require addititonal help when transferring. The Home also has a lift which is regulalry checked by qualified engineers (Standard 22) The management actively encourages residents to personalise their own bedrooms and are free to bring furniture and other personal belongings into their rooms. (Standard 23 and 24) The management ensure that a strict cleaning regime is in place so as to maintain the home is kept hygenically clean at all times. Staff are trained in how to deal with soiled linen and clothing so as to reduce the risk of the spread of foul smells and infection. In addition we have domestic staff who are training in NVQ2 awards specifically for cleaning and hygiene control (Standard 26) The inprovements made within the last twelve months included the purchase of a 2nd property next door to the existing building, to be used as an annex to Ashlee Residential Care Home. In addtion we have purchased a mobile screen to protect residents privacy. Provision of domestic hours has increased. And the plans for further improvements within the next twelve months were an extnsive revamp and extension to the existing premises. Work should commence sometime towards the end of the year. On the day of inspection: It was confirmed that the original plans to extend the property had required ammendment, which in turn had caused the delay in any alterations being made to the building. As the plans to extend the building had not yet commenced the ramp into the garden areas was unchanged, and as stated in previous reports this ramp is quite steep and would not be suitable for all residents who used wheelchairs to access this independently. Ashlee Care Home DS0000044372.V340494.R01.S.doc Version 5.2 Page 20 Three steps with a hand rail also provided access to the garden area for those residents who were mobile. Comments from the representative of one resident was “access into the garden is poor (ramp) /impossible and it is not a secure area”. This comment relates to the access from the rear garden area to the front of the property, which provides access to the road. The manager stated that some residents liked to sit in the seating area provided at the front of the building, however as the main road is accessible residents must be assessed to ensure they have the capacity to access the front of the home safely. Ongoing maintenance was undertaken as and when required and an example of this was new floor coverings that had been laid in all bathrooms and new carpets in three bedrooms. The laundry area was seen and housed suitable equipment to maintain disinfection standards. Residents spoken with were happy with the laundry services provided and confirmed that their clothes were always returned in a good condition and well ironed. Comments from residents and their representatives were positive regarding the standards of hygiene maintained at Ashlee. Ashlee appeared clean and fresh on the day of this inspection. Ashlee Care Home DS0000044372.V340494.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): 27,28,29,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs are met by a trained and competent staff team, and a thorough recruitment practice enhanced the protection of the residents. EVIDENCE: The written information provided by Ashlee prior to this inspection stated that: Ashlee Care Home does provide sufficient staff members and skill mix on duty at all times to meet the residents needs. Care staffing hours per week exceed those recommended by the Residential Forum Care Staffing in Homes for Older people program. (Standard 27) Great emphasis is placed on staff training by the management and an annual staff training planner with individual staff training plans helps the management regularly organise training courses for all staff members, so as to ensure that service users are cared for by well trained staff members. (Standard 28 and 30) The management has ensured the provision of a strict recruitment policy and will not offer any individual a position in the care home unless they pass the Ashlee Care Home DS0000044372.V340494.R01.S.doc Version 5.2 Page 22 rigid screening process. This includes the assurance that all Schedule 2 requirements of the national minimum standards (Care Standards Act) are met before a position in the organisation is offered. (Standard 29) Ashlee has increased the number of staff doing NVQ2 training from 50 to over 80 and the plans for the next twelve months included the current percentage of staff memebrs doing NVQ2 to rise from over 80 to 100 . Changes to the induction program at Ashlee which will replace the previously recognised 10 induction and foundation standards as directed by TOPPS to the new 6 CIS standards as directed by Skills for Care. On the day of this inspection: The staffing rotas were examined and provided sufficient staff numbers and skill mix on duty to meet the residents needs, the rotas also showed the waking night staff hours. Of the residents and staff spoken with, all said they felt the numbers of staff on duty were able to meet resident’s needs. As stated in the information provided by the home prior to inspection 80 of the care staff team are now trained to NVQ level 2 in care. This demonstrates the homes commitment to ensuring the staff at Ashlee have the skills and knowledge required to ensure that residents needs are met by a trained and competent staff team. Other training recently undertaken or planned for the near future included all mandatory training such as fire safety, moving and handling, food hygiene, and training that was specific to residents needs such as loss and bereavement and dementia training. Evidence was in place to demonstrate the induction programme in place as confirmed in the information provided by the home prior to this inspection. The recruitment information held for two members of staff was looked at and there was satisfactory evidence to demonstrate that a thorough recruitment practice was in place at Ashlee, which further enhanced the protection of the residents. Comments from residents and their representatives were positive and confirmed that the staff at the home were able to meet their needs well and staff were always available if they needed any help or support. Ashlee Care Home DS0000044372.V340494.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): 31,33,35,38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Ashlee is well managed and the health and safety of staff and residents is promoted and protected. EVIDENCE: The written information provided by Ashlee prior to this inspection stated that The registered manager completed the approved NVQ4 management course in Ashlee Care Home DS0000044372.V340494.R01.S.doc Version 5.2 Page 24 November 2005 and has also completed the assesors course in safeguarding adults training. In addtion the manager attends refresher courses every year in both of the above to maintain his status as both an NVQ level 4 approved manager and assessor in safeguarding adults training. (Standard 31) The manager regulalrly imparts his knowledge on staff memebers and guides and assists them in the application of their duties so that the managers own ethos is reflected in the staff members performance. (Standard 32) Residents have periodic meetings with the management and staff and also regularly complete satisfaction surveys, the results of which are collected and used to assist the staff and management in ensuring that the home is run in the best interests of the service users. (Standard 33) Whilst we encourage residents family members and representatives to handle service users financial arrangments, we are required to handle small amounts of money for residents for use with things like hairdressing, chiropody,etc. This is maintained under a robust system which is only ever handled by the manager and one of the comapanys directors. (Standard 34 and 35) The management ensures that all staff members undergo six supervision sessions and at least two appraisals every year. The process enables the mangement to assess the quality of the work provided by the staff and also helps highlight any shortfalls staff members may be encountering during the application of their duties. (Standard 36) The Home’s policies and procedures were all reviewed and revised at the beginning of the year by the management. (Standard 37) Fire records are well maintained and fire systems are regularly checked in accordance with the guidance given by the Fire Officer. Accident/Incident records are well maintained which demonstrate that any accident or incident is analysed and action is taken to prevent similar occurrences. The management ensures that Staff training is provided in Health and Safety. (Standard 38) On the day of this inspection: Care staff spoken with were complimentary regarding the management skills and ‘open door’ policy of the manager, and comments made included “ the manager is very good, he’s a great manager and is always available to discuss any concerns or issues”. Questionnaires were sent out every three months to residents, and to relatives twice a year. The results of these surveys were seen and the comments made were positive regarding the care and services provided. Residents spoken with confirmed that the manager / provider consulted and involved them in any changes within the home. Residents relatives or independent representatives continue to manage the residents finances and personal allowance. On the day of inspection some of he Ashlee Care Home DS0000044372.V340494.R01.S.doc Version 5.2 Page 25 residents had a small amount of money that was held for them in safe keeping at the home, only the owner/manager and his son had access to these monies. Transaction records for residents monies were held within the home and found to be satisfactory with the transaction record being signed on each transaction by the person completing it. As a matter of good practice it is recommended that two signatures are provided at each transaction, preferably the second signature being that of the resident. Some of the service/maintenance documentation was looked at and indicated that residents are protected by robust procedures, with evidence of gas services, water temperatures, hoist services and fire safety tests having been suitably checked/maintained. The manager confirmed that an electrical service had been undertaken on the 20 July of this year, and stated that the electrical service certificate had not been received at the time of this inspection visit. It was agreed that a copy of this certificate would be sent to the commission upon receipt. Ashlee Care Home DS0000044372.V340494.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 X 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 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 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 3 Ashlee Care Home DS0000044372.V340494.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP19 Regulation 23 Requirement The registered person must provide a timescale for providing a safe garden area for residents and improved ramp access (Previous timescale 30/06/06) Timescale for action 01/11/07 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. Refer to Standard OP35 Good Practice Recommendations As a matter of good practice two signatures are provided on residents financial transaction records and if possible one of these signatures be the resident’s. Ashlee Care Home DS0000044372.V340494.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!