Inspection on 17/06/05 for Ashleigh Court

This inspection was carried out on 17th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 15/11/05

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 ONeill Unannounced 17 June 2005 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 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 E54 S51010 AshleighCourt V228348 170605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Ashleigh Court Address 20 Fountain Road Edgbaston Birmingham B17 8LN 0121 420 1118 0121 420 1118 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Shanti Odedra Carol Ward Old Age 17 Category(ies) of Old Age registration, with number of places Ashleigh Court E54 S51010 AshleighCourt V228348 170605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Ensure appropriate locks are fitted to bedroom doors within six months of registration. 2. Ensure provision of an assisted bathing facility on the first floor within four months of registration. 3. Ensure provision of an assisted bathing facility on the second floor within six months of registration. 4. 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. 5. 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. 6. 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. 7. Install central heating in one single bedroom on the first floor that is currently without this facility within four months of registration. 8. Provide lockers and facilities for staff use within four months of registration. 9. Improve access to the garden area by provision of handrails within six months of registration. Date of last inspection 04/01/05 Ashleigh Court E54 S51010 AshleighCourt V228348 170605 Stage 4.doc Version 1.30 Page 5 Brief Description of the Service: Ashley Court is a care home providing care and accommodation for 17 older people. The home is located in a residential street that leads on to 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 E54 S51010 AshleighCourt V228348 170605 Stage 4.doc Version 1.30 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and the first of the statutory inspections for 2005/2006. The inspection was carried out over a morning and early afternoon in June. During the visit a tour of the premises was carried out, two resident’s files and two staff files were inspected as well as other care and health and safety records. The inspector spoke with the manager, senior care, proprietor, a care assistant and five of the fourteen residents. What the service does well: What has improved since the last inspection? What they could do better: There needed to be service user guide available for any prospective residents so that they would know what facilities the home offered. Ashleigh Court E54 S51010 AshleighCourt V228348 170605 Stage 4.doc Version 1.30 Page 7 The manager needed to be much more vigilant when employing staff to ensure all checks were undertaken so that the protection of the residents was assured as far as possible. All staff needed to receive training in what could constitute abuse and of how to report any allegation or suspicion of abuse. The home needed a quality assurance system so that the service on offer was constantly monitored taking into account the views of the residents. The home needed extensive redecoration and some replacement carpets, furnishings and mattresses. Some areas were quite shabby and no progress had been made on this since the last inspection. 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 E54 S51010 AshleighCourt V228348 170605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Ashleigh Court E54 S51010 AshleighCourt V228348 170605 Stage 4.doc Version 1.30 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 standard(s) 1, 2 and 4 Prospective residents would not be able to make an informed decision about whether the service offered at the home would meet their needs as the statement of purpose and service user guide were not available. The current residents were satisfied that their needs were being met. EVIDENCE: The manager of the home stated the statement of purpose and service user guide were still being updated and copies of these were not available for inspection. The service user guide needed to be available for any prospective residents to ensure they had some information about the home. There had been no new residents admitted to the home therefore the assessment procedure was not inspected and the requirement made following the last inspection has been brought forward to this report. All residents had been issued with a statement of terms and conditions of residence in the home. Ashleigh Court E54 S51010 AshleighCourt V228348 170605 Stage 4.doc Version 1.30 Page 10 Those residents spoken with were satisfied that their needs were being met. There was evidence on the daily records of personal care tasks being completed and of health care needs being met. There was also evidence on personal files of monthly evaluations of residents needs that documented progress or deterioration. There were some aids and adaptations throughout the home to assist those with mobility difficulties. Ashleigh Court E54 S51010 AshleighCourt V228348 170605 Stage 4.doc Version 1.30 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 standard(s) 7, 8 and 9. 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. The resident’s health care needs were being met and the systems for medicine management were good ensuring resident’s medication needs were being met. EVIDENCE: Two care files were sampled and both had care plans. 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 hoe the resident’s needs were to be met by staff and included choices to be offered and what the person could do for themselves. Both files did not contain enough detail in relation to personal care needs. For example one stated ‘full assistance’ but did not state what type of assistance, the other stated ‘she will do some things’ but there was no detail of what. The plans were being reviewed on a monthly basis but there was no evidence that either the resident or their representative had been party to the care plans. Ashleigh Court E54 S51010 AshleighCourt V228348 170605 Stage 4.doc Version 1.30 Page 12 Both files included up to date personal and manual handling risk assessments. The manual handling risk assessments needed to include details of the actions to be taken by staff if the resident fell and was not injured. 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 weights of the residents were being monitored where possible however as at the last inspection it was recommended that a chair scale was purchased to enable all residents to be weighed accurately. Tissue viability and nutritional screenings had been undertaken and where a risk had been identified in relation to pressure sores the action to be taken to minimise this was appropriately detailed on the individual’s care plan. Medicine management within the home continued to be good with only one or two very minor discrepancies which not have had a detrimental effect on the health and safety of the residents. The manager stated she had not rewritten the policies and procedures for medicine management as was required following the last inspection. Ashleigh Court E54 S51010 AshleighCourt V228348 170605 Stage 4.doc Version 1.30 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 standard(s) 12 and 15. There were no rigid rules or routines in the home and residents could spend their time as they chose. There were some organised activities for those residents who wished to take part. The residents were satisfied with the catering arrangements at the home. EVIDENCE: There did not appear to be any rigid rules or routines in the home. It was 8.55am when the inspector arrived at the home, some residents were having their breakfast, others had finished and others were getting up or still in bed. The residents spoken with stated they could spend their time as they chose. There was a record of activities and these included a recent garden fete, which had been very successful, bingo, exercise, and dominoes and sing a longs. Staff were keeping records of who had taken part in activities and who had declined. During the inspection residents were observed to wander freely around the home, watch television, reading and one playing cards. The menus seen were varied and nutritional and all residents that were able stated they were happy with the catering arrangements at the home. The residents appeared to enjoy their lunch on the day of the inspection and assistance was available from staff when needed. Food records were being kept. Ashleigh Court E54 S51010 AshleighCourt V228348 170605 Stage 4.doc Version 1.30 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 standard(s) 18 Staff were not aware of what constituted abuse or of the reporting procedures therefore the safety of the residents could not be ensured. EVIDENCE: Two complaints had been lodged with the CSCI since the last inspection. One was in relation to a broken tumble drier, how the laundry was being dried and a lack of protective clothing. This was not upheld. The second complaint concerned a missing gold locket which was not upheld in relation to the present proprietors, clothing going missing which was inconclusive, a resident being inappropriately dressed and a bedroom being untidy this was partly inconclusive and partly not upheld, inadequate staffing levels which was not upheld, a resident losing weight, this was not resolved due to the lack of records and a requirement was made of the home. The complaint was also in relation to the fees charged by the home which the CSCI have no influence over. The complaints procedure was not inspected therefore the requirement made following the last inspection has been brought forward to this report. The policies and procedures for adult protection were not inspected therefore the requirement made following the last inspection have been brought forward to this report. Ashleigh Court E54 S51010 AshleighCourt V228348 170605 Stage 4.doc Version 1.30 Page 15 It was documented on one of the resident’s daily records that there appeared to be several fingertip bruises on her arms. The records made by staff were very detailed however there was no evidence to suggest that this had been followed up in any way. The manager assured the inspector this had been followed up with staff and it was inappropriate handling. This was an adult protection issue and the appropriate social worker should have been contacted along with notification to CSCI. This would have enabled, as a minimum, a strategy discussion to take place to establish how this should have been pursued. Staff needed to have training in what constitutes abuse and the correct reporting procedures. Ashleigh Court E54 S51010 AshleighCourt V228348 170605 Stage 4.doc Version 1.30 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 standard(s) 19, 20, 21, 22, 24, 25 and 26. The standard of décor within the home was poor with no evidence of any improvement since the last inspection or of any planned improvements, therefore it does not present as homely and comfortable throughout for the residents. Several issues needed to be addressed to ensure the health and safety of residents and staff. EVIDENCE: Ashleigh Court E54 S51010 AshleighCourt V228348 170605 Stage 4.doc Version 1.30 Page 17 The location and layout of the home were suitable for its stated purpose. All the conditions of registration had been met by the proprietors which had improved the assisted bathing and showering facilities in the home, re-routed 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. It was strongly recommended that consideration be given to having a ramp installed in the garden area. Outstanding from the last two inspections was that the home was in need of extensive redecoration, some of the furnishings and several carpets needed to be replaced. The registered person needed to ensure that there was a programme of planned refurbishment and redecoration to ensure that all areas of the home were kept in a good state of repair and to an acceptable standard. A copy of this programme needed to be forwarded to the CSCI. To improve the safety of the residents and staff other issues that needed to addressed were: • The cracked floor tiles in the kitchen needed to be replaced. • The fraying carpets outside one of the bathrooms and the conservatory needed to be made safe. • Alternative storage space needed to be found for the foodstuffs on the top of the kitchen units as staff had to climb to reach them and there was also a risk of the items falling. • The emergency call system needed to be extended to cover all toilets, bathrooms, en-suites and lounge areas. • The practice of using wheelchairs without footrests and tilting them backwards to move residents needed to stop. • The fridge and freezer temperatures needed to be recorded on a daily basis to ensure they were working efficiently. • Food stored in fridges needed to be dated when opened. • There needed to be liquid soap and disposable towels available in all communal bathrooms, toilets and the laundry. • The heavily stained mattresses identified during the inspection needed to be replaced. All communal rooms were in need of redecoration and this must be included in the programme of refurbishment of the home along with replacing any worn furnishings. 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. Ashleigh Court E54 S51010 AshleighCourt V228348 170605 Stage 4.doc Version 1.30 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. Where items were not included through choice or other reason, this needed to be recorded in the resident’s file. The majority of the bedrooms were in need of decoration and several needed new carpets this needed to be included in the programme for refurbishment and redecoration. Some bedrooms did not have wash hand basins and this needed to be addressed. The heating, lighting and ventilation in the home met the needs of the residents and the home was generally clean. Ashleigh Court E54 S51010 AshleighCourt V228348 170605 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29. Staffing levels were adequate and staff were able to meet the needs of the residents. The appropriate checks were not being carried out when employing new staff potentially putting residents at risk. EVIDENCE: The staffing levels appeared to have improved and were meeting the required minimum of two care assistants plus a senior throughout the waking day. An additional member of staff was on duty to cover the cooking when required. The residents appeared very comfortable with the staff team and there were some friendly relationships evident. Residents were very positive in their comments about the staff team. The recruitment records for the two most recently employed staff were sampled. Neither contained all the required documentation. Application forms had been completed with declarations of offences and health declarations. Neither of the staff had been checked against the POVA register and neither had updated CRB checks. One had not given her former employer as a referee and this had not been appropriately pursued. Training was not assessed during this inspection therefore the requirements made following the last have been brought forward to this report. Ashleigh Court E54 S51010 AshleighCourt V228348 170605 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33,37 and 38. The manager was aware and had an understanding of areas the home needed to improve. Some of the issues needed prompt attention and a clear development plan needed to be followed to ensure the home was run in the best interests of the residents with their involvement. EVIDENCE: The manager had successfully completed the registration process with the CSCI since the last inspection. She had several years experience of working in residential homes and demonstrated a good knowledge of the residents in her care and the running of a care home. She needed to be much more vigilant when obtaining the required documentation for new employees and in the recognition of possible adult protection issues. She was undertaking her Registered Manager’s Award and was aware that this needed to be completed by 2005. Ashleigh Court E54 S51010 AshleighCourt V228348 170605 Stage 4.doc Version 1.30 Page 21 The manager appeared to have very good relationships with the residents and they appeared comfortable in her presence and talking to her. There had been no progress on implementing a formal quality assurance system in the home. The majority of records sampled were in order and up to date. The responsible individual for the home was not completing the monthly report on the conduct of the care home as required by Regulation 26 of the care homes Regulations 2001. There was evidence on site of the regular servicing of equipment and this was all up to date. All the internal checks on the fire system were up to date with the exception of the emergency lighting which was slightly overdue. Staff had received fire training and a fire drill had taken place. Some issues were raised in relation to the general safety of the building. Ashleigh Court E54 S51010 AshleighCourt V228348 170605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 x 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 3 28 x 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 1 2 3 1 x x x 2 1 Ashleigh Court E54 S51010 AshleighCourt V228348 170605 Stage 4.doc Version 1.30 Page 23 YES 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. Standard 1 Regulation 4(1)(c) schedule 1 & 5(1) Requirement Both the statement of purpose and the service user guide must be reviewed to ensure they contain all the relevant , current details. (Previous time scale of 14/03/04 not met.) The manager must ensure she obtaines a copy of the full social work assessment prior to admission to the home of residents. (Previous time scale of 01/03/05 not checked for compliance.) Residents care plans must detail all their needs in relation to personal care and how these are to be met by staff. There must be evidence that either the resident or their representative have been involved process. (Previous time scale of 01/10/04 not met.) Manual handling risk assessments must include details of the actions to be taken by staff in the event of a fall. (Previous time scale of 01/10/04 not met.) The policies and procedures for medicine management must be rewritten to reflect all practices Timescale for action 01/08/05 2. 3 14(1)(b) 01/08/05 3. 7 15(1) 01/08/05 4. 7 13(5) 01/08/05 5. 9 13(2) 01/08/05 Ashleigh Court E54 S51010 AshleighCourt V228348 170605 Stage 4.doc Version 1.30 Page 24 6. 16 22 7. 18 13(6) 8. 18 13(6) 9. 18 13(6) & 37 10. 19 23(2)(b) in the home. (Previous time scale of 01/04/05 not met.) The complaints procedure must be amended to ensure complainants are aware they can refer a complaint to the CSCI at any point. (Previous time scale of 01/03/05 not assessed for compliance.) The adult protection procedures must contain all the relevant guidance for staff to follow in the event or suspicion of abuse. (Previous time scale of 01/03/05 not assessed for compliance.) Staff must receive training in adult protection reporting procedures and what constitutes abuse. Any unexplained bruising on residents must be notified to CSCI. Where appropriate the adult protection procedures must be instugated. The registered person must develop a programme of planned refurbishment and redecoration to ensure that all areas of the home are kept in good state of repair and to an acceptable stanadard. (Previous time scale of 01/10/04 not met.) A copy of the programme must be forwarded to the CSCI. Alternative storage must be found for the food stuffs being stored on the top of the kitchen units. The frayed carpets outside the conservatory and the bathroom must be addressed. The cracked floor tiles in the kitchen must be replaced. The registered person must ensure that the emergency call system is extended to all communal areas, en-suite 01/08/05 01/08/05 01/09/05 18/06/05 01/08/05 11. 19 23(2)(l) 19/06/05 12. 13. 14. 19 19 22 13(4)(a) (b)(c) 23(2)(b) 23(2)(n) 20/06/05 14/07/05 01/09/05 Ashleigh Court E54 S51010 AshleighCourt V228348 170605 Stage 4.doc Version 1.30 Page 25 15. 22 13(4)(a) (b)(c) 16(2)(c) 16. 24 17. 24 23(2)(j) 18. 26 13(3) 19. 20. 26 26 13(3) 13(3) 21. 22. 26 28 13(3) 18(1)(a) 23. 29 19(1) & (2) schedule 2 facilities and all toilets and bathrooms. (Previous time scale of 01/10/04 not met.) The practice of using wheelchairs without footrests and tilting them backwards to move residents must stop. All rooms must be furnished in accordance with the standards and regulations. Where this is not required or appropriate, a record of this must be retained in the service user’s file. (Previous time scale of 01/01/05 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 scale of 01/04/05 not met.) Fridge and freezer temperatures must be recorded on a daily basis to ensure they working effectively. Any opened foods stored in the fridge must be dated on opening. There must be liquid soap and disposable towels available in all communal bathrooms and toilets and the laundry. The stained mattresses identified during the inspection must be replaced. 50 of care staff must be qualified to NVQ level 2 or the equivalent by 2005. (Previous time scale of 30/04/05 not assessed for compliance.) Staff files must include all of the documentation as stated in schedule 2 of the Care Homes Regulations 2001. (Previous time scale of 01/10/04 not met.) All staff must be checked against the POVA register before they commence their employment. 14/07/05 01/09/05 01/09/04 18/06/05 18/06/05 18/06/05 24/06/05 31/12/05 18/06/05 Ashleigh Court E54 S51010 AshleighCourt V228348 170605 Stage 4.doc Version 1.30 Page 26 24. 30 18(1)(c) (i) 25. 31 9(2)(b)(i) 26. 33 24(1)(a) (b) 27. 36 18(2) 28. 37 26 29. 38 23(4)(a) (c)(iv) (Previous time scale of10/01/05 not met.) The registered person must ensure that all staff have induction and foundation training in line with the specifications laid down by TOPSS. (Previous time scale of 01/03/05 not assessed for compliance) The manager of the home must be qualified to NVQ level 4 in care and management or equivalent by 2005. The home must introduce and implement an effective quality monitoring system in order to measure success in meeting the aims and objectives. (Previous time scale of 01/05/05 not met.) All staff must receive supervision at least six times peryear. (Previous time scale of 01/03/05 not assessed for compliance.) The responsible individual must prepare a monthly written report on the conduct of the home and forward a copy to the CSCI. (Previos time scale of 01/03/05 not met.) Emergency lighting must be checked on a monthly basis and records maintained. 01/08/05 31/12/05 01/08/05 01/08/05 01/08/05 18/06/05 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. Refer to Standard 8 19 Good Practice Recommendations It is recommended that achair scale be purchased. It is strongly recommended that a ramp is installed in the garden area. Ashleigh Court E54 S51010 AshleighCourt V228348 170605 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Birmingham and Solihull Local Office 1st Floor Ladywood House 45-46 Stephenson Street 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 E54 S51010 AshleighCourt V228348 170605 Stage 4.doc Version 1.30 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!