Inspection on 12/09/06 for Ashleigh Court

This inspection was carried out on 12th September 2006.

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

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

Other inspections for this house

Ashleigh Court 27/06/08

Ashleigh Court 18/07/07

Ashleigh Court 15/11/05

Ashleigh Court 17/06/05

Ashleigh Court 04/01/05

Ashleigh Court 03/08/04

Ashleigh Court 12/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Ashleigh Court 20 Fountain Road Edgbaston Birmingham B17 8LN Lead Inspector Jill Brown Key Unannounced Inspection 12th September 2006 10:35 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 Ashleigh Court DS0000051010.V311763.R02.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. Ashleigh Court DS0000051010.V311763.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashleigh Court Address 20 Fountain Road Edgbaston Birmingham B17 8LN 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) 0121 420 1118 F/P 0121 420 1118 Mrs Shanti Odedra Mr Sunil Odedra Mrs Carol Ward Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Ashleigh Court DS0000051010.V311763.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Mrs Ward must complete her Registered Manager’s Award by December 31st 2005 and evidence of this must be forwarded to the CSCI That two named people who are under sixty five years of age at the time of admission, can be accommodated and cared for in this home. 15th November 2005 Date of last inspection Brief Description of the Service: Ashleigh Court is a care home providing care and accommodation for 17 older people. The home is located in a residential street that leads onto the Hagley Road at the point that borders on the edges of the Edgbaston and Ladywood areas of Birmingham. Hagley Road is an arterial road into Birmingham and to Stourbridge and Kidderminster in the opposite direction. It is therefore well served by a bus service on this road. The home is sited in a large Victorian building. There is limited parking space at the front of the property but the road is reasonably quiet and some on the road parking is available. There is no front garden but there is a small garden at the rear of the property. The home has both single and shared rooms over the three floors most of which have en suite facilities. There is a passenger lift that gives access to these floors. Most of the en-suites would have difficulty accommodating the needs of a wheelchair user, the front of the house has steps and so does the rear garden. The home has two sitting areas, one that looks over the rear gardens. There are assisted bathing or showering facilities on each floor. The home charges between £314.00 and £370.00 per week. If residents need chiropody this is charged at £9.00 per visit, hairdressing costs vary. Ashleigh Court DS0000051010.V311763.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was unannounced and took place on a day in September and was over seven and half hours. During this visit five residents were spoken with as well as two staff, the manager and owner of the home. The inspector looked at care records of three residents and three staff employment files. A tour of the building was undertaken, medication administration records were sampled and a number of documents were looked at such as activity records, accident forms and so on. In addition to the visit information from notifications to the Commission, complaints and other contacts with the home were looked at to form this report. The Commission had a concern raised with it about the slowness of the homeowners to fix the boiler and the tumble drier in the home. This was resolved by them following contact by the Commission. What the service does well: Residents at the home were had their personal hygiene needs met and were treated with dignity and respect. A number of female residents had their nails painted and were wearing jewellery, which is important for some women. Residents said that they had no grumbles or complaints although two expressed the opinion that they would rather be at their own home, which is understandable. A number of residents were not able to voice an opinion but they showed no signs of ill being. Staff were seen to talk respectfully to residents and in one situation managed some difficult behaviour being displayed well. Residents are allowed to move around the home as they wish. Residents were given a formal choice of food and menus included snacks that were available. Food was well presented and residents that needed food cut up had this done without altering the nice presentation of the meal. The home received a very good report from the Food Safety Department on their unannounced check of the kitchen. The home has good information, Service User Guide, to give to residents and is currently looking again at their larger information document the Statement of Purpose to make sure that this gives residents and their representatives all the information they may want. Residents are protected by a contract often this is a contract with Social Care and Health as well. Ashleigh Court DS0000051010.V311763.R02.S.doc Version 5.2 Page 6 The home contacts the Commission if concerns are raised about the welfare of residents and this assists in ensuring residents are protected. The home for the most part was clean and fresh. The home showed that did checks on potential staff before employing them and this protects residents. It was clear that staff were receiving training in a number of areas. The home manages residents’ money well. What has improved since the last inspection? What they could do better: It was clear that the home had had a period where staffing levels were low and staff were working unacceptably long hours. This although resolved in August and September showed through on a number of key tasks. For example: - The monitoring of water temperatures, a lack of attention to infection control, poor record keeping on activities, lack of staff and resident meetings and irregular staff supervision. The assessment of residents needed to be more thorough to ensure information such as religious and cultural needs, moving and handling, dementia care needs are recorded and followed up in the resident’s plan of care. Care plans varied in the amount of detail they gave and how easy the information was to find quickly. Medication administration could be improved with some audits to ensure that medication is always administered and recorded appropriately. A number of improvements to the environment including redecoration, removing unwanted items from the garden and the provision of a ramp would improve the home for residents. The home needed to improve the areas of quality assurance and take account more regularly of staff and residents views as part of this process. The home needed to document this information gained from these consultations in a way that shows how the home intends to improve in this area. Ashleigh Court DS0000051010.V311763.R02.S.doc Version 5.2 Page 7 A matrix of staff’s attendance of various mandatory courses would be an invaluable planning tool and would ensure there were no gaps in training that may affect the wellbeing of residents. 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. Ashleigh Court DS0000051010.V311763.R02.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashleigh Court DS0000051010.V311763.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 & 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have information about the home before admission and have information about the terms and conditions of their stay. Improvements were needed in the assessment and confirmation that the home can meet an individual residents needs. EVIDENCE: The home provided its updated service user guide and this met the standards the updated statement of purpose is to follow shortly. Residents had three way contracts with the Social Care and Health and the home where necessary. On one file a change of room was not indicated on this agreement. Information was collected on residents to assist the admission into the home. The home’s format covers the main areas of care needed such as communication, health and so on needed but could be improved in the areas of cultural or religious needs, people’s memory and their mental state. Ashleigh Court DS0000051010.V311763.R02.S.doc Version 5.2 Page 10 A number of assessments were not clear about any diagnoses and reasons for admission into care. There were pre admission visits recorded these were not recorded in sufficient detail to ensure that a clear decision about whether the home can meet residents needs is recorded and the resident or their representative informed in writing. Ashleigh Court DS0000051010.V311763.R02.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The planning of care of residents varied and this could result in needs not being met. Medication administration and checking that needs are met could be improved to ensure the health of residents. Residents were treated with dignity and respect. EVIDENCE: Three residents’ care files were sampled during the inspection and the care planning in these files varied. One care file had very detailed plan that covered all identified needs and had useful information such as ‘does not like the upper front of body touched,’’ likes to get changed early for bed’ and in depth night time and eating care plans in place. However the information was not written in a way so someone could get the necessary information quickly. Another was not as good with not enough detail on how personal hygiene needs were to be met, poor moving and handling instruction despite the person using aids to walk and no skin assessment despite the lack of mobility and incontinence of the resident. Ashleigh Court DS0000051010.V311763.R02.S.doc Version 5.2 Page 12 The third care plan could have been improved to look at prevention of infection. Oral and foot care was missing on a number of care plans. Care plans were not always in place to meet mental health needs such as dementia. One daily record for a resident contained good information that could have been transferred into the care plan. Daily records showed that residents that said they were in pain or concerned about a health condition were referred to GPs or District Nurses to have these investigated. Residents had visits from chiropodists and opticians if needed. Residents were well dressed and had their personal hygiene needs met. A number of female residents had their nails attended to. A number of residents had just had their hair washed that morning in readiness for the hairdresser who unfortunately rang to say that they could not make it. One resident had a need identified for a high bed this was not seen in the resident’s bedroom and this could make it difficult for the resident to help himself or herself get out of bed. Medication Administration Records (MAR) were seen for two residents and a number of medications not in the monitored dosage cassette system. The records of medication were well ordered however the photocopied prescription scripts next to the MAR did not cover the same dates. This means a good practice check could not be undertaken. One eye drops medication had not been recorded as administered on three occasions. The count for a daily medication did not match the MAR record. One anti-inflammatory medication had run out and had yet to be replaced. A handwritten MAR did not have two signatures to ensure that the information was correct. The home has a system with as required pain relieving medication to ensure that there is an accurate count and this is good practice. During the inspection residents were seen and heard to be treated with dignity and respect. Those requiring assistance with personal care were helped discreetly. There was a telephone for the use of the residents however this was in the dining area and did not afford privacy when making or receiving calls and it is strongly recommended that the resident’s phone be located to a more private area so that they do not have to ask when wanting to make a private call. A number of female residents were wearing jewellery and had their nails painted and these were important to them. One resident said he would rather be at home but he has no complaints about the home and that staff were good. One resident with difficult behaviour was dealt with well and according to their care plan. Ashleigh Court DS0000051010.V311763.R02.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): 12,13,14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s systems of planning and recording did not ensure that all residents have activities or one to one time with staff. The arrangements for visitors, choice and meals were good and these enhance residents’ lives. EVIDENCE: On admission to the home ‘pop’ music was playing in the dining room, which reflects the choice of staff rather than residents. Although it was said that activities were being undertaken with residents none had been recorded in the activity book since April this year and individual plans did not show how residents that find it difficult to join groups have one to one time with staff. The activities co-ordinator had left the home since the last inspection. One resident said that she was bored but didn’t want to do activities but couldn’t say what would make her less bored. The home has a large television in the front lounge and there is a small library of books available. Another resident was happy with the singing and things and she mimed doing exercises. Relatives appear to be made welcome at the home at any time a number arrived at lunchtime and staff took this in their stride. Ashleigh Court DS0000051010.V311763.R02.S.doc Version 5.2 Page 14 Residents appeared to be able to walk around the home at will. A number of residents went out with relatives. Residents were encouraged to bring personal possessions into the home and these were observed in their bedrooms. Residents were able to have breakfast when they wanted and food was available before the cook’s shift started. The inspector watched the serving of the lunchtime meal residents had a choice of gammon or cod roe, or tomatoes and fried eggs. The meal was well presented. The inspector noted that residents that needed assistance by having their meat cut up had the meat cut in a presentable way. Residents that that needed their food pureed had all the foods to pureed together. Discussion with the cook agreed that separating the food may give the residents individual tastes and this should be tried with the residents in question. The menus showed a range of foods available at meal times and at snack times. The home had a food safety department visit in April and had no requirements made. Ashleigh Court DS0000051010.V311763.R02.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): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Whilst the home has not received complaints from residents they need to ensure they have methods for routinely collecting their views. Residents are protected as far as possible form abuse. EVIDENCE: The home had amended its complaint procedure to ensure that concerns about the process of handling a complaint could be referred to the Commission at any point. The home had not had recent resident meetings and this is a way of ensuring that the residents’ grumbles are picked up and dealt with. The Commission received a complaint about the home’s slowness in dealing with breakdowns of the heating and the tumble dryer. This was resolved by the provider. The Commission has been informed of two incidents that could be of an adult protection nature and the home has dealt with these appropriately. The home has informed the Commission of a further incident that happened recently from the information available to the inspector at the time of the inspection it appears that this could not have been predicted. Residents had inventories taken of their belongings and this ensures their safety. Residents’ personal allowance is managed appropriately where necessary. Ashleigh Court DS0000051010.V311763.R02.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): 19,21,25, & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had made a number of improvements to the environment further improvements were needed to ensure that residents have a safe, clean and pleasant surroundings. EVIDENCE: The home was working on improvements to the environment and a number of previous requirements had been attended to. The garden looked well maintained however still not accessible to all residents. A number of bedrooms were to be redecorated from the previous inspection report. Not all bedrooms were seen on this inspection and this requirement was brought forward as well as the requirement about wash hand basins being available in bedrooms. Ashleigh Court DS0000051010.V311763.R02.S.doc Version 5.2 Page 17 The home had heightened the sidelights to prevent residents getting burns from the bulbs. The main lounge lights were a bit low and may cause difficulties for tall people. The home had not monitored the water temperatures in the home for some months and this may mean that the residents are subjected to too cool or warm water. The home was generally clean and fresh on the day of the inspection. However there were a number of items that required attention to maintain good infection control. The shower room on the second floor had a shower chair that needed cleaning. The ventilation fans in en suites needed cleaning and one was not working and over the toilet seat had rust that could cause a skin tear. A fabric towel was seen in a bathroom and the staff toilet had not paper towels. The mops were also outside of the building and not appropriately stored out of the water. Ashleigh Court DS0000051010.V311763.R02.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): 27,28,29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels were not at a consistent level and staff were working excessive hours and this potentially puts residents at risk. Recruitment practices and training for staff were improving and further small improvements would ensure that residents can feel the benefit of a well trained staff group. EVIDENCE: The rotas showed that the staffing in the home has been stretched for a number of months with staff undertaking excessive numbers of hours. Rotas submitted with the pre-inspection questionnaire showed where the manager and the care staff were working over 55 hours per week and on occasions over 60. Staffing levels were so low that the manager having to provide support on the floor. However rotas for August and September showed that this had got better with staff appearing to work only exceptionally over 40 hours per week. Staffing levels had improved to 3 in the morning and 3 in the afternoon with a manager available and this level must be maintained. Staff files must also show that staff have agreed to working over 48 hours per week and this agreement must be regularly reviewed. The home is almost reaching the appropriate number of staff trained to NVQ 2 level. Ashleigh Court DS0000051010.V311763.R02.S.doc Version 5.2 Page 19 The three staff files looked at showed that prospective staff complete an application form. The application form does not give enough space for people to understand that all employment details need to be recorded so that the gaps in employment can be discussed. References are applied for and received however the home must check that by either headed notepaper or company stamp that these references are genuine. In one case the references were translated into English and this is good practice. Staff have appropriate police checks. It was clear that staff have been on several courses one member of staff spoken to was undertaking the infection control training. Another had undertaken a lot of training in the key required areas. The home did not have a matrix of the training that the whole staff group had undertaken and so it was not possible to say that the home met the standard on this. Induction processes were not inspected on this visit. Ashleigh Court DS0000051010.V311763.R02.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): 31,33,35,36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the management of the home is experienced and able the lack of staffing has affected the monitoring arrangements in the home. There was evidence of that this had improved in the last two months but this must sustained if residents are to remain safe. EVIDENCE: The registered manager had several years experience of working in homes for older people and demonstrated a good knowledge of the residents in her care and the running of a residential home. She was very committed to meeting any requirements made following the inspection. Ashleigh Court DS0000051010.V311763.R02.S.doc Version 5.2 Page 21 It was clear that the home had been under some pressure for some months and key monitoring tasks had not been undertaken such as the monitoring of water temperatures, activities log and staff and residents meetings had not been undertaken for several months. Although the home has some quality assurance activity such as regulation 26 visits on behalf of the provider a full quality assurance system is not in place. The home manages some money for most of its residents. A number of residents’ money is managed by their relatives and the home manages a small float of money for example for chiropody hairdressing on their behalf. The home was able to explain the way the amounts of money was determined in light of the individual resident’s need for cash and had no concerns about this. The money held by the home matched the home’s records; receipts for money spent were kept. The home’s supervision of staff was variable in one situation a member of staff had not had supervision since January in another newer member of staff had three supervision sessions. Supervision sessions when they occurred were appropriate and dealt with performance and training issues. The home was ensuring routine maintenance and inspection of services of the home was being undertaken. The home was able to show the inspector certificates for the gas and electrical installations being inspected and there was no repair work required. The home had checks of the fire safety equipment and had recently reviewed their fire risk assessment. The home was due a fire drill imminently and must ensure that all staff have the benefit of regular fire drills. The homes call alarm bells were installed in 2005 and could now benefit from a maintenance check. The premises risk assessment was not looked at however a number of items needed work. The side of the building had items that needed to be removed such as an old fridge freezer. One over the toilet seat was rusty and this must be attended to prevent the possibility of skin tears. A window restrictor was not in place on the ground floor toilet window, which led to a drop of about 4 and half feet. Ashleigh Court DS0000051010.V311763.R02.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 2 3 2 X 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X 2 X X X 2 2 STAFFING Standard No Score 27 1 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X X 2 X 2 Ashleigh Court DS0000051010.V311763.R02.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes Ashleigh Court DS0000051010.V311763.R02.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 OP1 Regulation 4(1)(c) Sch 1 & 5 Requirement The statement of purpose must be further developed to ensure they include all the relevant information. (Previous time scales of 14/03/05 01/08/05 and 01/01/06 partly met) Assessments of residents needs should include cultural, religious, and mental health needs. Timescale for action 30/11/06 2 OP3 14(1)(a) (d) 31/10/06 3 OP7 15(1) 4 OP7 13(5) 5 OP7 15(1) 12 (1)(a) The registered manager must ensure that prospective residents or their representatives receive written confirmation that the home can meet their needs. Residents care plans must detail 30/11/06 all their needs in relation to personal care and how these are to be met by staff. (Previous time scales of 01/04/05, 01/08/05 and 01/01/06 not met) Manual handling risk 31/10/06 assessments must include details of the actions to be taken by staff in the event of a fall and include any handling methods. (Previous time scales of 01/10/04 01/08/05 and 01/01/06 not met) Where residents are receiving 31/10/06 treatment for mental health conditions the home must ensure DS0000051010.V311763.R02.S.doc Version 5.2 Page 25 Ashleigh Court 6 7 OP8 OP9 12(1)(a) 13(2) that the care plan contains information on relapse triggers. The home must ensure that the where needs are identified they are met. Handwritten Medication Administration Records (MAR) must have two signatures. The home must ensure that residents have enough medication to meet the need as prescribed. All medications must be given as prescribed. The home must ensure that the residents views are collect to aid their complaint and audit processes. There must be a programme of planned refurbishment and redecoration to ensure that all areas of the home are kept to an acceptable standard. (Previous time scales of 01/10/04, 01/08/05 and 01/01/06 not met) 31/10/06 31/10/06 8 OP16 22(2) 30/11/06 9 OP19 23(2)(b) 30/11/06 10 OP24 23(2)(j) 11 OP25 13(4)(c) A copy of the programme must be forwarded to the CSCI. (Previous time scale of 01/08/05 not met) Any bedrooms without en-suite 30/11/06 facilities must have a wash hand basin fitted with a supply of hot and cold water. (Previous time scales of 01/04/05 and 01/09/05 not met) This was not inspected on this occasion. The home must investigate the 31/10/06 raising of the chandelier in the front room. The home must ensure that water temperatures are monitored routinely through out Ashleigh Court DS0000051010.V311763.R02.S.doc Version 5.2 Page 26 12 OP26 13(3) 13 OP27 18(1)(a) the home. The home must ensure that the infection control in the home be improved by: • Removal of fabric towels in communal bathrooms. • Inspecting commodes and over toilet seats for cleanliness and rust. • Ventilation fans must be cleaned and working. • Mops must be stored appropriately. Staffing levels must be kept at a consistent level. 31/10/06 31/10/06 14 15 OP28 OP29 18(1)(a) 19(1) Sch 2 16 OP30 18(1)(a) Any staff agreeing to work over 48 hours must sign a declaration and this must be reviewed routinely. Fifty percent of staff must be 31/12/06 qualified to NVQ level 2 or the equivalent. The application for employment 30/11/06 form must be further developed to ensure it allows applicants to insert all the relevant information. (Outstanding since 01/01/06) There must be documented 30/11/06 evidence that staff have received induction training in line with the standards and time scales detailed by Skills for Care. (Previous time scales of 01/03/05 and 01/08/05 not met) This was not inspected on this occasion. A matrix of the staff groups attendance at training must be produced and a copy sent to the Commission by The manager of the home must be qualified to NVQ level 4 in care and management or equivalent by 2005. (Awaiting certification) DS0000051010.V311763.R02.S.doc 17 OP31 9(2)(b)(i) 31/12/06 Ashleigh Court Version 5.2 Page 27 18 OP33 24(1)(a) (b) The home must introduce and implement an effective quality monitoring system in order to measure success in meeting the aims and objectives. (Previous time scales of 01/05/05, 01/08/05 and 01/02/06 not met) There must be regular resident and staff meetings or consultation to feed into the quality assurance system. All care staff must have at least 6 times a year. There must be evidence on site that the emergency call system is regularly serviced. (Outstanding since 01/01/06) The premises risk assessment must be further developed to ensure it covers all areas. The existing premises risk assessments must be reviewed. (Not inspected on this occasion) The fridge freezer must be removed from the side of the building. The ground floor toilet must have a window restrictor fitted. 31/12/06 19 20 OP36 OP38 18(2) 23(2)(c) 31/12/06 31/10/06 21 OP38 13(4)(c) 31/12/06 22 23 OP38 13(4)(c) 13(4)(c) 31/10/06 31/10/06 OP38 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP9 OP10 OP18 Good Practice Recommendations It is recommended that a copy of the prescription is kept with the relevant MAR. It is strongly recommended that the phone used by the residents be relocated to ensure it affords privacy. It is strongly recommended that a concise step by step DS0000051010.V311763.R02.S.doc Version 5.2 Page 28 Ashleigh Court 4. 5. OP19 OP29 procedure be developed for staff to follow in the event or suspicion of abuse as a quick reference guide for them. It is strongly recommended that a ramp be installed in the garden area. It is recommended that references be validated by either headed paper or the company stamp of the person supplying the reference. Ashleigh Court DS0000051010.V311763.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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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