Inspection on 15/11/05 for Ashleigh Court

This inspection was carried out on 15th November 2005.

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 12/09/06

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 Brenda O’Neill Announced Inspection 15th November 2005 09:45 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.V254660.R01.S.doc Version 5.0 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.V254660.R01.S.doc Version 5.0 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 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.V254660.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Provide lockers and facilities for staff use within four months of registration. Ensure appropriate locks are fitted to bedroom doors within six months of registration. Ensure provision of an assisted bathing facility on the first floor within four months of registration. Ensure provision of an assisted bathing facility on the second floor within six months of registration. Close and block off multiple access points into bathrooms, providing only one access door, to promote and protect privacy for service users within six months of registration. Create an alternative access to the fire escape on the second floor rather than the current route through a service user bedroom. This change to take place within twelve months or use of this room as a service user bedroom to cease. Create additional space for first floor bedroom currently used as a route through to the fire escape by utilising some floor space from an adjacent bathroom. At the same time, to provide an alternative access to fire escape rather than through this bedroom. This change to take place within twelve months of registration or cease to use this room as a bedroom for service user. Install central heating in one single bedroom on the first floor that is currently without this facility within four months of registration. Improve access to the garden area by provision of handrails within six months of registration. Mrs Ward must complete her Registered Manager`s Award by December 31st 2005 and evidence of this must be forwarded to the CSCI 6. 7. 8. 9. 10. Ashleigh Court DS0000051010.V254660.R01.S.doc Version 5.0 Page 5 Date of last inspection 17th June 2005 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 which looks over the rear gardens. There are assisted bathing or showering facilities on each floor. Ashleigh Court DS0000051010.V254660.R01.S.doc Version 5.0 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and carried out over one day in November 2005. This was the second of the two statutory visits for this home for 2005/2006. To get a full overview of all the standards assessed during this inspection year this report should be read in conjunction with the report written following the inspection on 17th June 2005. During this visit a partial tour of the premises was made, two resident and two staff files were inspected as well as other health and safety records, care documentation and some policies and procedures. The inspector spoke with the manager, proprietor, two staff on duty at the time and three of the thirteen residents. What the service does well: What has improved since the last inspection? The assessment procedure for new residents had improved ensuring staff knew the needs of the residents prior to admission. Staff had received training in adult protection issues ensuring they knew how to recognise and report appropriately any issues that may arise. There were documented details of how wheelchairs were to be used to ensure the safety of the residents. Ashleigh Court DS0000051010.V254660.R01.S.doc Version 5.0 Page 7 The CSCI were receiving regulation 26 visit reports that gave an ongoing overview of the conduct of the home and also acted as a quality monitoring tool. There had been discussions with the residents or their representatives as to the suitability of the furnishings in their bedrooms. Some of the bedrooms had had new carpets fitted and the requirements made in relation to safe food storage at the last inspection had been met. 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. Ashleigh Court DS0000051010.V254660.R01.S.doc Version 5.0 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.V254660.R01.S.doc Version 5.0 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, 3 The statement of purpose and service user guide needed to be further developed to ensure prospective residents had all the necessary information to enable them to make an informed choice as to where they lived. The assessment procedures for the home were good and ensured the staff knew the needs of the residents prior to admission. EVIDENCE: The statement of purpose and service user guide for the home were viewed. Both documents needed to be further developed to ensure they included all the necessary information including such things as the staffing structure for the home, staff training and the age range of the residents. The complaints procedure also needed to be amended to ensure that complainants were aware they could lodge a complaint with the CSCI at any time. There had been no new residents admitted to the home for some time however the manager had undertaken an assessment of a prospective resident. A prospective resident had visited the home for a pre admission day and the staff had carried out an assessment during this time. The documentation used for the assessment included all the required areas as well as a general needs Ashleigh Court DS0000051010.V254660.R01.S.doc Version 5.0 Page 10 sheet which gave likes, dislikes and preferences and a personal information sheet. The individual concerned was outside the registration category for the home in relation to age. The manager had completed a variation for this and handed it to the inspector during the visit. The individual had also been assessed by a social worker and the manager was awaiting her assessment prior to arranging an admission date. Ashleigh Court DS0000051010.V254660.R01.S.doc Version 5.0 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, 10 The care planning system in the home was good. Further development was needed in relation to detailing personal care needs to ensure staff knew how to meet all the needs of the residents. Any actions taken to restrict the movement of the residents around the home must be clearly documented in care plans as they may be deemed as restraint. The resident’s health care needs were being met. EVIDENCE: Two care plans were sampled during this visit. As at the last inspection there was a lot of detail about individual resident’s needs included on the files, for example, there were personal preference sheets. The care plans covered a wide variety of topics including, mobility, eating and drinking, communicating and socialising. Some of the areas documented included very good detail of how the resident’s needs were to be met by staff and included choices to be offered and what the person could do for themselves. One of the files did not include enough detail in relation to personal care needs, for example, there was no mention of oral care or if the individual bathed or showered and no details of if she was able to do anything for herself. The other care plan was better and included such things as ‘is able to wash her own hands and face but not the rest of her body.’ The care plans were being reviewed on a monthly Ashleigh Court DS0000051010.V254660.R01.S.doc Version 5.0 Page 12 basis and there was some evidence that either the resident or their representative had been party to them. There were manual handling risk assessments included on the files however these both stated ‘before attempting to assist to stand’ but did not detail how staff were assist or if any handling would be necessary. There were also some risk assessments in relation to nutrition and pressure care but these did not always correspond with the care plan. For example, one risk assessment stated the individual had her food liquidised but the care plan stated it was cut up. The manager needed to ensure that any risk assessments were cross referenced to the care plans to ensure consistency by staff. There was evidence of some challenging behaviour on one of the care plans and this did give some details of how staff were to manage this but there was no corresponding risk assessment for this. It was also noted that one of the residents was in a recliner chair and when asked about this the manager stated it was for health and safety reasons. There was no documentation on the residents care plan in relation to this and it could be deemed as restraint. Any actions that restrict the movement of the residents around the home needed to be clearly detailed on care plans as to why this is being done and be reviewed regularly. There was documented evidence of personal and health care needs being met on daily records and on sheets entitled ‘quick reference professional visits’. These evidenced that G.P.s, district nurses, nurse practitioners and chiropodists were visiting the residents as necessary. The residents weights were being monitored wherever possible however as at the last inspection it was recommended that a chair scale be purchased to enable all residents to be weighed accurately. During the inspection residents were seen and heard to be treated with dignity and respect. Those requiring assistance with personal care were helped discreetly. Medical consultations took place in the privacy of residents’ bedrooms. Residents could see their visitors in their bedrooms or one of the quieter areas in the home. All residents could have keys to their bedrooms if they wished and all had a lockable facility and all double rooms were equipped with appropriate screening. 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. The manager stated that if residents wanted to make private calls they could use the office phone however 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. Ashleigh Court DS0000051010.V254660.R01.S.doc Version 5.0 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): 13, 14 Residents were encouraged to exercise choice and control over their lives wherever possible. There were no restrictions on visitors to the home within reasonable hours. EVIDENCE: There did not appear to be any rigid rules or routines in the home. Residents were observed to spend time in the lounge, dining room, playing cards, watching television and returning to their rooms as they wished. The residents spoken with confirmed they chose when to get up and when to go to bed, what to eat, what to wear and so on. Residents were encouraged to bring personal possessions into the home and these were observed in their bedrooms. Some of the residents continued to hold small amounts of money for themselves. There did not appear to be any restrictions on visiting within reasonable daytime hours. One relative visited the home during the course of the inspection and appeared to be made welcome by staff. Ashleigh Court DS0000051010.V254660.R01.S.doc Version 5.0 Page 14 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): , Residents were issued with a complaints procedure however this needed to be amended to ensure they were aware they could lodge a complaint with the CSCI at any time. To ensure the protection of the residents staff had received training in adult protection issues and there were appropriate policies and procedures on site. EVIDENCE: There had been no complaints made to the home since the last inspection and none had been lodged with the CSCI. There was a complaints procedure on site and this was issued to the residents in the service user guide, however this needed to be amended to ensure any complainants were aware they could lodge a complaint with the CSCI at any time. Some issues were raised at the last inspection in relation to the staff’s awareness of recognising and reporting any issues of adult protection appropriately. At the time of this inspection all staff had received training in adult protection issues and this included how to report any issues. There were appropriate policies and procedures on site and also a copy of the updated multi agency guidelines for adult protection. It was strongly recommended that a concise step by step procedure be developed for staff to follow in the event or suspicion of abuse as a quick reference guide for them. Staff had also received training in challenging behaviour since the last inspection. As mentioned previously the manager needed to ensure that any actions taken that could be deemed as restraint were clearly documented in the individual’s Ashleigh Court DS0000051010.V254660.R01.S.doc Version 5.0 Page 15 care plan as to why the action was being taken and it must be subject to frequent review. Ashleigh Court DS0000051010.V254660.R01.S.doc Version 5.0 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, 20, 21, 22, 24, 25, 26 The standard of décor within the home was poor with no evidence of any improvement since the last inspection. There needed to be a programme of planned refurbishment and redecoration to ensure that all areas of the home were kept to an acceptable standard. Some issues needed to be addressed to ensure the health and safety of the residents. EVIDENCE: The home was suitable for its stated purpose and there had been no changes to the layout since the last inspection. All the conditions of registration, as stated at the beginning of the report, had been met by the proprietors which had improved the assisted bathing and showering facilities in the home, rerouted fire escape routes so that they did not impinge on the privacy of residents and improved access to the garden by the fitting of handrails at either side of the steps, however, this area would still not be accessible to service users in wheelchairs. As at the last inspection it was strongly recommended that consideration be given to having a ramp installed in the garden area. Outstanding from the last three inspections was that the home was in need of extensive redecoration and some of the furnishings needed to Ashleigh Court DS0000051010.V254660.R01.S.doc Version 5.0 Page 17 be replaced. The inspector was informed that redecoration to several areas of the home was due to commence shortly after the inspection. The manager needed to ensure that there was a programme of planned refurbishment and redecoration to ensure that all areas of the home were kept to an acceptable standard. A copy of this programme needed to be forwarded to the CSCI to enable progress to be monitored on future inspections. Some improvements had been made since the last inspection including several bedrooms had had new carpets, the fraying carpets had been addressed, there was safe food storage in the kitchen and the issue raised in relation to the use of wheelchairs without footrests had been addressed by documenting how staff were to use the chairs in residents’ files. Issues that remained outstanding were: • • The cracked floor tiles in the kitchen needed to be replaced. The emergency call system needed to be extended to cover all toilets, bathrooms, en-suites and lounge areas. Issues that were raised during this inspection in relation to health and safety were: • The portable radiator in the conservatory needed to be guarded, as the surface temperature was very hot. • Action needed to be taken to ensure the residents could not burn themselves on the bulbs in the wall lights in the ground floor corridor. These lights were located at a low level and the bulbs were exposed above the shades. • The surface temperature of the radiator in the bedroom identified during the inspection must not exceed 43 degrees. This was excessively hot at the time of the inspection. • The seal on the fridge in the kitchen was split and needed to be replaced. There was adequate communal space however the rooms remained in need of redecoration and some of the furnishings needed to be replaced. This must be included in the programme of refurbishment. Ashleigh Court DS0000051010.V254660.R01.S.doc Version 5.0 Page 18 Resident’s bedrooms contained a variety of furniture and fittings and were appropriately personalised to the occupant’s choosing. Some rooms did not have all of the items specified in the National Minimum Standards, for example two chairs. This had been discussed with the residents since the last inspection and recorded in their files where they did not require additional furniture. Several of the bedrooms were in need of decoration and this needed to be included in the programme for refurbishment and redecoration. Several had had new carpets since the last inspection. Some bedrooms did not have wash hand basins and this needed to be addressed. There were adequate assisted bathing and showering facilities in the home to meet the needs of the residents. There were some aids and adaptations to assist those with mobility difficulties including, a shaft lift, hand and grab rails. The home was found to be clean and odour free. Ashleigh Court DS0000051010.V254660.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Appropriate staffing levels were being maintained with a generally well trained staff team who were able to meet the needs of the residents. There needed to be evidence that new staff had received appropriate induction training to ensure they were equipped to fulfil their roles. Further improvements were needed to the recruitment procedures to ensure the residents were not put at risk. EVIDENCE: The appropriate staffing levels were being maintained and the manager was in the process of recruiting a domestic assistant which will allow the care staff more time with the residents. The staff team had been a little more stable over the past two inspections which was good for the continuity of care of the residents. The residents were very comfortable in the presence of the staff and friendly relationships were evident. The recruitment records for the two most recent employees at the home were inspected. The application form at the home needed to be further developed as it did not allow space for the referees to be put in and there was little space for former employers. The recruitment procedures had improved and the vast majority of the required documentation was available. There had been an issue where the manager of the home had apparently been given incorrect information in relation to CRB and POVA first checks and this was to be taken up by the inspector. One of the files had two references but one was not from the most recent employer and there was no explanation as to why, there was Ashleigh Court DS0000051010.V254660.R01.S.doc Version 5.0 Page 20 no proof of I.D. or of a staffs eligibility to work in this country on one of the files. The training records were checked for the same employees and although one had received some training at a previous home there was no evidence of any induction for either member of staff. The manager needed to ensure that there was documented evidence that staff had received induction training to ensure they were equipped with the appropriate skills and knowledge to fulfil their role. The manager had developed an induction programme but this needed to be cross referenced to the standards and time scales laid down by Skills For Care. The ongoing training for staff in the home was generally good. Training records evidenced that staff completed courses in, food safety, fire training, health and safety, infection control, adult protection and manual handling. Of the ten care staff employed four had completed NVQ level 2 or above which is just below the minimum requirement of fifty percent however others were undertaking this qualification. Ashleigh Court DS0000051010.V254660.R01.S.doc Version 5.0 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37, 38 The manager ensured the smooth running of the home in a competent manner. To ensure the comfort and the safety of the residents some issues needed to be addressed. 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 and there had been a noticeable improvement in recruitment procedures and the recognition of adult protection issues. She was undertaking her Registered Manager’s Award. There were some basic ways of monitoring quality in the home, for example, resident and relative satisfaction questionnaires and regulation 26 visit reports. However there had been no progress on implementing a formal quality assurance system in the home. Ashleigh Court DS0000051010.V254660.R01.S.doc Version 5.0 Page 22 The manager handled some monies on behalf of the majority of the residents. The records for these were sampled and found to be appropriate with receipts available for expenditure and two staff signatures where residents were unable to sign the records. All the cash balances checked at the time of the inspection agreed with the written records. The system was audited every three months by two staff. There was a system of staff supervision in the home however the required number of six sessions per year for each staff member was not being reached. Further improvements were required to recruitment records and care plans. Other records were generally well ordered and up to date. The inspector had been receiving the monthly reports, in line with Regulation 26 of the Care Homes Regulations, in relation to the conduct of the care home. Health and safety were generally well managed. The majority of staff had received training in safe working practices and there was protective clothing available on site when needed. There was evidence on site of the servicing of all equipment, with the exception of the emergency call system, all the in house checks on the fire system were up to date and there was evidence that the water system had been checked for the prevention of legionella. There were premises risk assessments on site but these needed to be further developed to ensure they covered all areas, for example, hot surfaces and those that were available were in need of review. Other issues that were raised included the unguarded radiator in the conservatory and exposed light bulbs. Ashleigh Court DS0000051010.V254660.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 2 3 2 X 2 2 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 2 2 2 Ashleigh Court DS0000051010.V254660.R01.S.doc Version 5.0 Page 24 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 OP1 Regulation 4(1)(c) sch 1 & 5 Requirement Timescale for action 01/01/06 2 OP7 15(1) 3 OP7 13(5) 4 OP7 13(4)(c) The statement of purpose and service user guide must be further developed to ensure they include all the relevant information. (Previous time scales of 14/03/05 and 01/08/05 not met) Residents care plans must detail 01/01/06 all their needs in relation to personal care and how these are to be met by staff. (Previous time scales of 01/04/05 and 01/08/05 not met) Manual handling risk 01/01/06 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 and 01/08/05 not met) All risk assessments must be 01/01/06 cross-referenced to care plans to ensure the information detailed is consistent. Any aspects of challenging behaviour must be clearly documented in a risk assessment. Ashleigh Court DS0000051010.V254660.R01.S.doc Version 5.0 Page 25 5 OP7 13(6) 6 OP16 22 7 OP19 23(2)(b) Any actions taken that restrict 01/12/05 the movement of any residents must be clearly documented on care plans and detail why the actions are being taken and be reviewed on a regular basis. The complaints procedure must 01/01/06 be amended to ensure complainants are aware they can refer a complaint to the CSCI at any point. (Previous time scales of 01/03/05 and 01/08/05 not met) There must be a programme of 01/01/06 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 and 01/08/05 not met) A copy of the programme must be forwarded to the CSCI. (Previous time scale of 01/08/05 not met) The seal on the fridge must be replaced or anew fridge purchased. The cracked floor tiles in the kitchen must be replaced. (Previous time scale of 14/07/05 not met) The registered person must ensure that the emergency call system is extended to all communal areas, en-suite facilities and all toilets and bathrooms. (Previous time scales of 01/10/04 and 01/09/05 not met) Any bedrooms without en-suite 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) The portable radiator in the conservatory must be guarded. DS0000051010.V254660.R01.S.doc 8 9 OP19 OP19 23(2)(b) 23(2)(b) 01/01/06 14/12/05 10 OP22 23(2)(n) 01/01/06 11 OP24 23(2)(j) 01/01/06 12 OP25 13(4)(c) 22/11/05 Page 26 Ashleigh Court Version 5.0 13 OP25 13(4)(c) 14 OP25 13(4)(c) 15 16 OP28 OP29 18(1)(a) 19(1) sch 2 Action must be taken to ensure the residents cannot burn themselves on the exposed bulbs in the wall lights. The surface temperature of the radiator in the bedroom identified must not exceed 43 degrees. Fifty percent of staff must be qualified to NVQ level 2 or the equivalent. The application for employment form must be further developed to ensure it allows applicants to insert all the relevant information. Wherever possible one reference should be from the most recent employer. There must be evidence that staff are eligible to work in this country. (Previous time scales of 01/10/04 and 18/06/05 partially met) There must be documented 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) The manager of the home must be qualified to NVQ level 4 in care and management or equivalent by 2005. (Previous time scale given had not expired) 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 and 01/08/05 not met) There must be evidence on site DS0000051010.V254660.R01.S.doc 22/11/05 22/11/05 31/12/05 01/01/06 17 OP30 18(1)(a) 01/01/06 18 OP31 9(2)(b)(i) 31/12/05 19 OP33 24(1)(a) (b) 01/02/06 20 OP38 13(4)(c) 01/01/06 Page 27 Ashleigh Court Version 5.0 21 OP38 13(4)(c) that the emergency call system is regularly serviced. The premises risk assessment must be further developed to ensure it covers all areas. The existsing premises risk assessments must be reviewed. 01/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP8 OP10 OP18 OP19 Good Practice Recommendations It is recommended that a chair scale be purchased. It is strongly recommended that the phone used by the residents is relocated to ensure it affords privacy. It is strongly recommended that a concise step by step 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 is installed in the garden area. Ashleigh Court DS0000051010.V254660.R01.S.doc Version 5.0 Page 28 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. Extracts may not be used or reproduced without the express permission of CSCI Ashleigh Court DS0000051010.V254660.R01.S.doc Version 5.0 Page 29 - 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. 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