Inspection on 21/11/06 for Ashlee Lodge

This inspection was carried out on 21st November 2006.

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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashlee Lodge 14/02/06

Ashlee Lodge 09/08/05

Ashlee Lodge 03/02/05

Ashlee Lodge 03/08/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Ashlee Lodge 5 Jameson Road Bexhill on Sea East Sussex TN40 1EG Lead Inspector June Davies Unannounced Inspection 21st November 2006 10:00 Ashlee Lodge DS0000061465.V318980.R01.S.doc Version 5.2 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 Ashlee Lodge DS0000061465.V318980.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 Adults 18-65. 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 Lodge DS0000061465.V318980.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashlee Lodge Address 5 Jameson Road Bexhill on Sea East Sussex TN40 1EG 01424 220771 01242 220771 ashleelodge@tiscali.co.uk 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) Ashlee Lodge Limited Lindsey-Anne Baker Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Ashlee Lodge DS0000061465.V318980.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated may not exceed five (5). That the category of registration be learning disability with challenging behaviour, not falling within any other category. Service users must be aged between eighteen (18) and sixty-five (65) years on admission. Date of last inspection Brief Description of the Service: Ashlee Lodge is a small detached Victorian house, providing residential and social care for adults with a learning disability and potentially challenging, or self-injurious behaviours. The home was re-registered in June 2004 under the ownership of the parent company, Allied Care Limited, which owns a large number of similar care homes, in the Southeast region. The home is registered for five people. Residents private rooms are on the first and second floors. There are sufficient communal spaces, including a spacious lounge, dining room a sensory room and bathroom facilities on each floor. The home is located in a quiet residential area of Bexhill-on-Sea, within easy walking distance from the shops and seafront. Fees Charged are £1350.00 to £1500.00. Ashlee Lodge DS0000061465.V318980.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a Key inspection carried out over a period of 6.5 hours in November 2006. There were five female service users in residence. The inspector spoke with two service users, two members of staff, the registered manager on the day of this inspection. The inspector also telephoned three parents, a social worker and care manager, to seek their views of the quality of care offered by the home. A tour was made of the premises, and relevant documentation was also viewed. The inspector observed one to one care being given by the staff in the home, and had lunch with two of the service users. What the service does well: What has improved since the last inspection? The registered manager ensures that the home continues to be well maintained, and recently the communal areas of the home have been redecorated. The manager did purchase some wooden dining room chairs, but within six months all had been broken, and the inspector was shown evidence of this. All records are kept up to date, including care plans, policies and procedures. The registered manager has also reviewed all the ‘umbrella’ policies and procedures adopted by Allied Healthcare, and customised them to meet the circumstances of Ashlee Lodge. The registered manager has almost completed the quality assurance survey for the home, and now needs to publish the findings of this survey together with her audit of care plans, reviews, medication, menus, cleanliness and staff training. Ashlee Lodge DS0000061465.V318980.R01.S.doc Version 5.2 Page 6 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 Lodge DS0000061465.V318980.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashlee Lodge DS0000061465.V318980.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. The registered manager ensures that pre-admission assessments contain sufficient information, to enable the home to meet the needs of the service user. EVIDENCE: The inspector viewed the care plans for the five service users who live in the home. Each care plan contained a pre-admission assessment. Care Managers had carried out three pre-admission assessments and these also contained information from multi disciplinary teams and were seen to be comprehensive providing the home with sufficient evidence on which to base a care plan. For two service users who were emergency placements, the preadmission assessment was carried out after the placement. This was discussed with the registered manager, who said that she had received help from Community Learning Disability Team to ensure that a full assessment took place, with detailed information on which to base the care plan. Preadmission assessments contained information on family contacts, contacts to the multi disciplinary team (general practitioners, behavioural specialists, psychiatrist, psychologist, speech therapists, care manager and social workers), together with personal care needs, social care needs, medication, Ashlee Lodge DS0000061465.V318980.R01.S.doc Version 5.2 Page 9 diets, food likes and dislikes, communication techniques, mobility, behaviours, self harming, risk assessments and restrictions made for the safety of the service user. The inspector also spoke with a member of staff, who stated that assessments and care plans gave staff good information on the care needs of the service users. Ashlee Lodge DS0000061465.V318980.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans contain detailed information, which is updated at regular reviews to ensure that the care needs of the service users are met. Service users are helped to make decisions about their lives, and are well supported in this by the care staff team. Service users are enabled to maintain their health care and lifestyle choices and risks are identified to support this. EVIDENCE: Five care plans were viewed and found to be comprehensive with individual information relating to the present care needs of the service users, including well written risk assessments, planned therapeutic programmes, dealing with aggressive and challenging behaviour, showing how the home needs to maintain a structured environment to maintain the service users sense of security. The care plans also contained information regarding the communication needs of the service users, which included the use of Makaton signing, flash cards, and communication boxes. Risk assessments were Ashlee Lodge DS0000061465.V318980.R01.S.doc Version 5.2 Page 11 printed on yellow paper so that staff can easily access them in the care plan. Due to the severity of the service users disability none of them are able to understand their care plans. The care plans are reviewed on a six monthly basis. Sometimes this has taken a little more than six months, to ensure that all members of the multi-disciplinary teams and family can attend the reviews. Due to the restricted abilities of the service users they are only able to make easily understood decisions, but these are recorded in their care plan. Communication is difficult for the service users and this precludes any meaningful discussion, between service users and staff. Staff have learnt how to read body language, which can be useful in reading the service users wishes, and times of discontent. The inspector was able to observe two members of staff communicating at a very simple level with the service users, this communication related to a lunch time meal and a trip out in the afternoon. Service users are able to carrying out household tasks that would cause minimal risk. All care plans contained a variety of risk assessments with clear instructions for staff to ensure that risk is kept to a minimum. The home has an up to date policy and procedure for unexplained absences. There have been no unexplained absences from the home in the last three years, occasionally service users try to abscond while out in the community, but staff know how to re-act to the individual service user when this occurs. Ashlee Lodge DS0000061465.V318980.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported to take part in social activities of their choice. Contact with families and friends are supported by the home. Meals are provided that meet the dietary needs and choices. EVIDENCE: Service users are encouraged to develop their lifestyle within their abilities; one service user has a part-time job and attends a college course. Some service users with their key workers take part in words and numbers sessions in the home. The inspector obtained information relating to service users personal development via the care plans, telephone discussion with relatives, care manager, a social worker and from observation between a service user and member of staff during the key inspection. Each service user has their own weekly activity sheet and these demonstrated that service users have a wide range of stimulating activities they are able to take part in. Service users go in to the community on a daily basis, they are well known in the local shops. Two out of the five service users are supported Ashlee Lodge DS0000061465.V318980.R01.S.doc Version 5.2 Page 13 by two staff on trips out of the home. On a weekly basis some service users are able to use most forms of public transport, to pursue their own interests in other local towns. Forthcoming local community events are displayed on a board in the dining room, this is as a reminder to staff, who will then communicate a forthcoming event to the service users. The service users have no understanding of political issues, and therefore do not get involved in local or general elections. Staff are always available in sufficient numbers to escort the service users into the community in the evenings and at weekends. All activities are recorded on each service users daily report within the care plan, also contained within the care plan are risk assessments relating to service users activities, with good guidance on how challenging and aggressive behaviour can be minimised. The home has encouraged and supported service users to build and maintain relationships with their families. Evidence was available via the care plans and through telephone discussions with relatives, a social worker, and care manager, of how service users are taken to meet and perhaps go for a meal with their families. One service user is now able to visit their relative for a holiday. Via telephone conversation, families told the inspector how they were involved in the reviews of the service user. All families told the inspector how happy they were with the care and attention their daughters received at Ashlee Lodge. Service users are encouraged to develop friendships outside the home, and occasionally visit other local homes owned by Allied Healthcare to meet up with friends they have made in these homes. One service user has a personal relationship, and the registered manager with the assistance of the Community Learning Disability Team ensures that this service user is given the best possible support in a format that can be understood by the service user. Decisions in relation to daily routines by the service users are made within a framework of risk assessments. All decisions and involvement in activities are recorded on each individual service users daily report sheet. Staff were observed respecting the privacy and dignity of the service users, all personal care is given behind closed doors. Doors to service users bedrooms are lockable, but staff members can open these locked doors in a case of emergency. Three service users are able to open their own mail, and two service users show no interest in their mail, but staff sit with these service users when their mail is opened. When in the home the emphasis is very much on one to one working with the service user, during trips into the community two service users need the support of two staff. It was noted during the inspection that a service user does not like to use her bedroom. The registered manager was able to explain why this was, and evidence was also available in the service users care plan. Service users are offered nutritious meals at flexible times. The inspector viewed the menus, observed food being served and sat down to have lunch with two service users. The service users food likes and dislikes are recorded in their care plan. One service user has an eating disorder and staff have found the finger and buffet food is more acceptable. Weight charts are kept in Ashlee Lodge DS0000061465.V318980.R01.S.doc Version 5.2 Page 14 each service users care plan, and there was evidence that service users are weighed on a regular basis. Ashlee Lodge DS0000061465.V318980.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensures that service users receive good personal and health care, using the skills of the multidisciplinary teams. The systems for medication administration are good with clear and comprehensive arrangements being in place to ensure service users medication needs are met. EVIDENCE: Staff offer flexible personal support to all the service users, who all need the assistance of staff for personal hygiene needs. All personal care is carried out in the privacy of the service users own bedroom or communal bathroom. All personal care is recorded in the service user’s own daily report. None of the service users need support with mobility. All but one of the service users is able to shop for clothes of their choice. Four of the service users are able to visit the hairdresser of their choice. Each week service users are given a choice of staff to work with them. Two out of the five service users require two S.C.I.P trained staff with them in the community at all times. All the service users have aids to assist with communication, and some of the aids used are communication boxes, flash cards, and Makaton signing. Key workers spend one to one quality time with their service users to promote communication. Ashlee Lodge DS0000061465.V318980.R01.S.doc Version 5.2 Page 16 Service users are unable to manage their own health care needs due to the severity of their disability. Service users are able to choose their own G.P., who they feel comfortable with. All but one service user is able to access dentists, opticians and therapists of their choice. The continence nurse gives staff and service users advice on appropriate continence aids. When service users need to attend hospital they have two staff to accompany them. Service users health is monitored on a daily basis by care staff and any concern is logged in the daily report and discussed at staff changeover. All concerns are reported directly to the service user’s G.P. Families told the inspector how the registered manager and staff keep them well informed in relation to any health concerns. Evidence was available on the care plans to show that medication is reviewed on a regular basis. One service user’s, mother told the inspector how the registered manager had worked with the G.P. to ensure the prescribed medication was suitable for that service user, and how much the correct medication had changed her daughters life. Due to the challenging and sometimes aggressive behaviour from the service users, there is always one member of staff present during G.P., community nurse and continence nurse visits. The home uses a monitored dosage system for medication, the inspector did note that some medication cannot be blister packed. The inspector carried out a full audit of medication, and found that MAR sheets had been completed accurately. Medication coming in and going out of the home is accurately recorded. The medication corresponded with the MAR sheet. The home has up to date policies and procedures (reviewed January 2006) for the administration of medication together with very clear PRN guidelines (reviewed in September 2006). Only staff that have completed medication training are allowed to administer medication, and the inspector was shown an up to date list of staff that had been trained together with their signatures and initials. The inspector did note that external medication was kept in the same storage box as internal medication. The home at present does not use controlled drugs. Ashlee Lodge DS0000061465.V318980.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 & 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and relatives can be confident complaints will be listened to and dealt with appropriately and the service users will be protected from abuse. EVIDENCE: The homes complaints policy and procedure was reviewed in October 2006, and is included in the statement of purpose and service user guide. The home has had four complaints since the last inspection, and the inspector was able to ascertain, that all these complaints were recorded, appropriately investigated, and the person making the complaint was informed of the outcome within 28 days The home has recently reviewed policies and procedures for the protection of vulnerable adults, including managing challenging behaviour and whistle blowing. Staff are made aware of these policies and procedures during the course of their induction. All policies and procedures are openly available to the staff in the home. The home has had one adult protection incident since the last inspection, which was reported by the registered manager to all appropriate authorities, due to the way in which the manager dealt with this situation the adult protection alert is now closed. All the service users personal monies are looked after by the home, and this was seen by the inspector to be dealt with in a secure and appropriate way, with regular checks being carried out against expenditure and recording, on each staff shift change over. Ashlee Lodge DS0000061465.V318980.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of the environment within the home is good providing service users with a homely place to live. The home needs to improve in the control of cross infection and odour, to ensure the well being of the service users. EVIDENCE: The inspector carried out a tour of the home. Ashlee Lodge is well maintained, communal rooms have recently been redecorated, and there is a planned programme of maintenance and replacement. Bedrooms were bright and cheerful. In accordance with a requirement made at the last inspection the registered manager purchased some wooden dining room chairs, since then all these chairs have been broken, and the registered manager has had to resort back to metal framed chairs with plastic seats. The registered manager and member of staff told the inspector this is the third lot of chairs that has Ashlee Lodge DS0000061465.V318980.R01.S.doc Version 5.2 Page 19 been purchased by the home in as many years. The inspector witnessed that all radiators in the home were covered. Letters were available in the office to show that the home meets the requirements of the local fire safety officer and the environmental health officer. Looking at the fire book records, fire drills and fire point checks, the inspector noted that the fire point checks are not carried out regularly and is making a requirement that this check should be carried out on a weekly basis. The premises were clean and hygienic with the exception of Room 5, and the inspector has made a requirement, that the odour in this room is investigated, and dealt with. The home has a policy and procedure to prevent the spread of infection. The inspector did note that the ground floor staff room had a towel rather than paper hand towels, and has made a recommendation for the provision of paper towels. The registered manager explained that it was difficult to have paper hand towels in other parts of the building as they always get put down the toilet, and this caused the drains to block up. The home has a separate laundry, which is situated behind the kitchen. All soiled linen is placed into alginate bags before being taken to the laundry for washing. The laundry room is fitted with an industrial washing machine, which has a sluicing and disinfecting programme. The home has a contract with a waste disposal company for the disposal of incontinence aids. All staff are provided with plastic aprons and disposable gloves when dealing with bodily waste and spillages. Ashlee Lodge DS0000061465.V318980.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Recruitment practices need some improvement to ensure that service users receive care from staff that have been appropriately vetted. Both mandatory and job related training needs to improve to ensure that staff are able to meet the assessed needs of the service users. EVIDENCE: The inspector looked at personnel files for five of the staff. All files contained two or three written references, CRB checks and two files had POVA first checks, statements of terms and conditions of employment. The company does need to ensure that the application is reviewed so that a full employment history can be obtained. Due to the disability of the service users they are not able to take part in the selection process, but the registered manager does insure that potential new staff visit the home for three shifts, to meet the service users, and to read the policies and procedures of the home, these staff are employed for a three month probationary period. At the time of the inspection the registered manager was not aware of the GSCC code of conduct, but has assured the inspector that she will obtain these booklets and ensure Ashlee Lodge DS0000061465.V318980.R01.S.doc Version 5.2 Page 21 they are given to every member of staff. The inspector was able to speak with two members of staff both confirmed that they had completed an application form, provided names and addresses of referees, obtained a current CRB check and received terms and conditions of employment, one member of staff said that she was undergoing her probationary period of employment. The inspector viewed the training and development plan held in the home, it was noted that some of the training was out of date and that certificates needed to be renewed. The registered manager confirmed that she had recently written a letter to Allied Healthcare head office to request training for staff, the inspector is making a requirement that staff mandatory and job related training is kept up to date. When viewing the training plan the inspector noted that 62.2 of staff have NVQ level 2. Ashlee Lodge DS0000061465.V318980.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered manager is supported well by the senior staff in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. Service users benefit from a well run home where their health and safety is promoted and protected. EVIDENCE: The registered manager has completed her NVQ level 4 and at the present time is completing her RMA; she has also obtained A1 and D2 assessors awards. She is well aware of the aims and objective of the home, and has a number of year’s experience of managing a specialist residential care home. Ashlee Lodge DS0000061465.V318980.R01.S.doc Version 5.2 Page 23 The registered manager has recently completed POVA training and training the trainer’s award. Two staff spoken to said, the manager provides them with good support. The inspector also had telephone conversations with three parent, a social worker and care manager all stated that the manager has excellent skills and is very supportive to the service users, families and the multi disciplinary team. Allied Healthcare and the registered manager have developed a quality assurance system for the home, and this includes an annual development plan, questionnaires to service users, families, stakeholders and staff. Due to the disability of the service users it is difficult to seek their views in regard to the management of the home and the quality of care they expect. The registered manager also carries out audits every six months, on policies and procedures, medication, care plans, reviews, menus, cleanliness of the home and staff training. The manager is working towards publishing the quality assurance findings on the questionnaires and audits. The home has policies and procedures for maintaining the health and safety in the home both for the service users and staff, and these are due for review in December 2006. Most staff have received training in moving and handling, fire safety, first aid, food hygiene and infection control, and further training is to be arranged in the New Year. The home does have a COSHH cupboard, which is situated in the basement of the building and the entrance to the basement is kept locked at all times. The kitchen also has a small locked cupboard where chemicals in current use are kept. The home has COSHH risk assessments and data sheets. All appliances used in the home have up to date maintenance certificates. All hot water outlets are checked monthly to ensure that hot water is delivered at 43ºC. All windows have window-opening restrictors fitted. The building is secure with a keypad fitted to the front door (integrated into the fire system) and the back door has an ordinary lock. This back door leads out into a secure garden area. The inspector also viewed the risk assessment for the whole premises, checks are carried out on a regular basis, and any issues are addressed immediately. All staff receive Health and Safety training during their induction. Ashlee Lodge DS0000061465.V318980.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 X 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Ashlee Lodge DS0000061465.V318980.R01.S.doc Version 5.2 Page 25 No 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. 2. Standard YA30 YA34 Regulation 16(2)(k) Requirement Timescale for action 01/01/07 3. 4. YA24 YA35 The registered manager must keep the home free from offensive odours. (Room 5) Schedule The company needs to revise its 15/01/07 2(6) application form to enable applicants to give a full employment history. Schedule Fire call points must be tested 01/01/07 4(14) on a weekly basis and records of testing kept up to date. 18(1)(a)(c) The registered person shall 01/03/07 19(5)(b) ensure that at all times suitably qualified, competent and experience persons are working at the care home in such numbers as are appropriate for the health and welfare of the service users. This must include mandatory and job related training. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000061465.V318980.R01.S.doc Version 5.2 Page 26 Ashlee Lodge 1. 2. Standard YA2 YA16 Any future admissions to the home must be accompanied by a pre-admission assessment from a Care Manager. Further remedial work should be identified with assistance from the multi-disciplinary team to encourage a service user to make full use of their bedroom. Internal medication should be stored separately from external medication to prevent cross contamination. Staff cloakroom to be provided with paper hand towels to prevent the risk of spreading infection. The registered manager to publish the findings of quality assurance questionnaires and audits. 3. 4. 5. YA20 YA30 YA39 Ashlee Lodge DS0000061465.V318980.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Ashlee Lodge DS0000061465.V318980.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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