Inspection on 18/07/07 for Ashleigh Court

This inspection was carried out on 18th July 2007.

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 12/09/06

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 18th July 2007 09:15 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.V340968.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ashleigh Court DS0000051010.V340968.R01.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.V340968.R01.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. 12th September 2006 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.V340968.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An inspector visited the home on a day in July without prior notice. A key inspection was undertaken which looked at all of the key standards. The inspection took place over 8 hours. During the inspection 2 residents were case tracked. This case tracking involved talking to the residents looking at all the records and information about them, looking at their medication, their rooms and talking to relatives and staff. This was to help the inspector make a judgement about the care given. Other residents and relatives were also spoken to. The inspector also took into account information we had received from all sources about the home since the last inspection. Information was given to us in an Annual Quality Assurance Assessment (AQAA), which the home completed. The AQAA shows how the home rates their performance in the areas set out in this report. We received this AQAA before the inspection. We had a concern raised with us about the home following the last key inspection this was about an admission of resident into hospital in a poor state. Although there were areas where the home needed to improve a poor discharge from hospital prior and the resident’s health conditions made this worse. A random inspection was carried out following this and this inspection is also contained in this report. Recently the home accommodated seven residents from another home on emergency basis a concern was raised about bruising to two residents. This was looked into and was not a concern about the home’s practice. There were twelve people resident at the home at the time of the key inspection. What the service does well: Residents were encouraged to maintain contacts and services that they had in the community before they were admitted to the home. Residents appeared to have their personal care needs met and received checks of their health, by health care professionals shortly after admission. Residents and relatives spoken to were happy with the care provided. A representative said ‘I’m happy with the care here its not posh but its homely.’ Relatives and representatives were made welcome in the home one said ‘staff at this home look after relatives as well as residents.’ Ashleigh Court DS0000051010.V340968.R01.S.doc Version 5.2 Page 6 The meals were well cooked and nutritious a resident said that meals ‘they are excellent I have never refused anything.’ Another resident said ‘The food is good I’ve put on weight.’ There is a visit to the home by a representative of the provider every month and a report of that visit is written. What has improved since the last inspection? What they could do better: The home needed to ensure where a mental health need was identified that the staff were made aware in the care plan of signs and symptoms that would show that the resident’s mental health was deteriorating. Where residents have continence issues at night a care plan should be written. A number of residents had infections recently and to ensure good infection control procedures are in place an audit of infections should routinely be undertaken. Residents needed more choice of activities. Residents that were able had opportunities to go out in the community these opportunities need to be more available to residents that need escorting. Residents needed more opportunities to raise concerns and issues about the service the home provides. Staff need to be more consistently trained in key areas; this includes adult protection, fire safety, food hygiene and medication administration. Although opportunities have occurred for staff to be trained these have not been taken up and the owners and manager must look to reason for this and rectify it as this can affect the service to residents. Ashleigh Court DS0000051010.V340968.R01.S.doc Version 5.2 Page 7 The recent extreme weather has shown some deficiencies in the building. Water has entered the building and the plasterwork in several residents’ bedrooms has been affected. This must be rectified as this can have an affect on residents’ health. Two residents bedrooms do not have a wash hand basin fitted and this must be attended to without undue delay. A ground floor toilet has a window which opens wide enough to allow residents to get out, there is a significant drop on the outside of the window. The home has not fitted a window restrictor as required. Staff recruitment needed to be improved to ensure all appropriate checks were completed for all staff. Staff did not receive induction in the way recommended by the Skills for Care organisations Common Induction Standards. There needed to be a more thorough compliance to Fire safety practices to ensure all staff have the relevant training and experience of fire drills. Previous requirements to have an opening restrictor on the window in the ground floor toilet and for a fridge freezer to be removed from the garden were still outstanding. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ashleigh Court DS0000051010.V340968.R01.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.V340968.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are admitted on the basis of a thorough assessment and have the benefit of visiting the home before admission and this helps to ensure that placements are successful. EVIDENCE: Residents funded by social services had the benefit of a three-way contract to ensure their rights. There were no copies of letters showing the home sent letters to residents or their representatives saying that they can meet the resident’s needs. New residents to the home had in depth assessments undertaken. Information was collected with residents on their day assessment visits and this information put together with information from other sources such as social workers and hospital ward staff. Ashleigh Court DS0000051010.V340968.R01.S.doc Version 5.2 Page 10 As well as collecting information about resident’s health conditions and personal care needs information about residents preferences around food and activities were also collected. Residents ethnic background and religion were recorded to ensure that the home is able to meet residents’ needs. Relatives spoken to said their relative had a choice of which home to go to their relative had tried this home and another but preferred Ashleigh Court. She liked this home because she talked to the other residents and the chef and liked the food. The home had one male member of care staff. This means that male residents do not always have the option of having care provided by a man. All the residents were from a white UK or White Irish background the staff group is culturally diverse. Ashleigh Court DS0000051010.V340968.R01.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. 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. Care plans whilst improving have gaps that may mean residents’ needs are not met. Small improvements are needed in medication administration as this ensures residents health needs are met. EVIDENCE: The residents case tracked were new admissions and both had a care plan and this was an improvement on previous inspections. Care plans covered the majority of areas of identified need in the assessment. One resident did not have information about their depression and nighttime continence problem. The information in the care plans reflected the residents concerned and the inspector was able to identify the resident from the information. Ashleigh Court DS0000051010.V340968.R01.S.doc Version 5.2 Page 12 Care plans included information on risks with residents having nutritional, the safety of residents’ skin, mobility and falls and moving and handling risks assessed. These assessments were reviewed and where necessary plans put into place to ensure future. A resident had a risk assessment in place about using the lift when it was found that they were using the stairs unsafely a risk assessment was put in place and action was taken. Care plans were reviewed with the admitting social worker and family four weeks or so after admission and routinely monthly after that. The four week reviews said ‘..has settled well and enjoys the company and care wishes to remain at the home.’ ‘..happy with the services provided and her needs are met.’ ‘..happy with the care said that the home put her first.’ Residents were observed to have their personal hygiene needs met and generally residents’ clothes and hair were attended on both the random and key inspections. One relative said, when asked, that their relative personal hygiene needs had been met. On the day of the inspection one resident was having their hair attended to by the hairdresser that undertook this task when she was in the community and this continuity is good practice. Residents care plans showed that residents maintained appointments they had in the community with health professionals and other contacts were made to secure the residents’ health and well-being. Visits for the chiropodist had been arranged and one resident had attended the eyes hospital and the other had GP appointments. Residents were weighed routinely and the home has purchased some sit on scales to ensure that this task could be accomplished more easily. Medication administration was administered in a satisfactory way. There were no gaps of signatures on the medication administration record (MAR) showing that staff signed for medication as it was administered. The counts of medication tallied with the MAR in all but one case. There was a copy of the relevant prescription next to the relevant MAR and this is good practice as it ensures that the dispensed medication can be checked against what the doctor has prescribed. One medication did not have the amount of tablets the resident was admitted with recorded and this meant that it was not possible to audit that particular medication. A number of residents had antibiotics prescribed in the previous 28 days. The medication administration could be improved further by ensuring that a photograph of new residents is put next to the relevant MAR, more staff undertaking medication administration training and an audit of infections in the home. Ashleigh Court DS0000051010.V340968.R01.S.doc Version 5.2 Page 13 Residents, relatives and representatives spoken to were happy with the care given in the home. A representative said ‘I’m happy with the care here its not posh but its homely.’ Staff were observed to talk to residents appropriately and approach residents appropriately by giving them time to move around and achieve tasks. Ashleigh Court DS0000051010.V340968.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for visitors, choice and meals were good and these enhance residents’ lives. Activities needed to be broadened to ensure that all residents benefit from activities and community involvement. EVIDENCE: Daily activities residents preferred were recorded in the resident’s assessment paperwork. Activities undertaken were recorded in resident’s daily records as well as in a daily activities folder although this was not always completed. For one resident the activities enjoyed were watching the TV, reading, dominoes, listening to the radio, talking to staff and residents and ball games. The resident was observed walking around the home with the radio and talked about listening to the radio when spoken to. Another resident had lots of visitors, had their hair done and spent time reading. One resident would like to attend church some distance away and this has not been organised as yet although a local church does attend the home. A Ashleigh Court DS0000051010.V340968.R01.S.doc Version 5.2 Page 15 relative said that they had seen staff playing dominoes with residents and engaging in some activities although some residents did not wish to join in. One resident wanted space for jigsaws and the manager stated that this would be organised and immediately thought of a way this could be achieved. Care planning showed specific residents interests but did not ensure that residents had one to one time with staff or that they all had opportunity to be assisted in the community. Relatives and representatives of residents are made welcome in the home. One relative said ‘staff at this home look after relatives as well as residents.’ Another representative said that they visit daily and staff are very friendly. It was noted that a number of visitors stayed to have a meal with their relative. Other visitors were routinely offered drinks, visitors said this was not unusual and these were carried to the place wherever they wanted to talk to their relative. Residents spoken to did not seem concerned about the routines in the home. A resident spoken to says that they get up early at 8am for breakfast but then they always got up early. Another said ‘I get up when I want and go to bed when I want. Residents walk around the ground floor unrestricted. The inspector joined residents for a meal the choice was boiled gammon or roe with two vegetables and potatoes. At this meal residents had the benefit of soft meat that was easy to eat and a good range of vegetables. The meat was not salty. This was very well cooked and presented. The menus provided by the home show a 4 week rolling menu. There is a choice at each mealtime. Residents can have a hot breakfast and a hot option at teatime, usually something on toast, everyday. One resident said of the meals ‘they are excellent I have never refused anything.’ Another resident said ‘The food is good I’ve put on weight.’ Ashleigh Court DS0000051010.V340968.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements for residents to raise concerns needed to be improved to ensure their safety and wellbeing. Staff needed to trained to ensure their awareness of adult abuse issues. EVIDENCE: Since the last key inspection there have been two issues raised under adult protection procedures. The first was in connection with an admission to hospital of a resident. An investigation was undertaken and a random inspection undertaken subsequently. The concern was raised about the lack of information sent with a resident to the hospital and resident’s poor physical state on admission to hospital. The home had developed a hospital admission form subsequently and this was a good format and should assist in ensuring hospitals receive the appropriate information when residents are presented there. Investigation prior to the random inspection found that the resident’s previous discharge from hospital had not followed expected protocol and it was likely a residential home would not be able to meet the resident’s new needs. The resident’s health had deteriorated since discharge. The resident’s behaviour made personal hygiene care difficult for all that attended to her including district nurses and hospital staff as well as staff at the home. Ashleigh Court DS0000051010.V340968.R01.S.doc Version 5.2 Page 17 The second incident was about bruising found on 2 of seven residents admitted to the home in an emergency. This was investigated and one was thought to have happened during transportation to the home and the second was thought to be a result of known behaviour of the resident. Accident records since the beginning of the year showed an incident of unexplained bruising; the manager investigated this and it was consistent with a fall. There were few accidents recorded. The homes complaint procedure has been revised to ensure that residents can contact us if they need to. The homes complaint procedure is prominently displayed, as is our fact sheet about abuse. Residents spoken to knew who they would raise a complaint with and felt safe to do so. Not all staff have received adult abuse awareness training. There has not been a residents’ meeting recently. Residents had inventories taken of their belongings and this ensures their safety. Residents’ personal allowance is managed appropriately where necessary. Ashleigh Court DS0000051010.V340968.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Remedial action is needed in the environment to ensure the health and wellbeing of residents. EVIDENCE: A tour of the building was undertaken the communal areas were looked at and some bedrooms sampled. A number of previous requirements and recommendations about the building and the garden had not been met. The Annual Quality Assurance Assessment (AQAA) did not give any undertaking that these will be completed in the next 12 months. Whilst the home had wash hand basins available to fit into rooms without them these had not been fitted. The chandelier in the front lounge had not been raised. The home was clean and fresh and well ordered. The recent exceptional weather had shown that there were problems with the fabric of the building Ashleigh Court DS0000051010.V340968.R01.S.doc Version 5.2 Page 19 and there was water damage to several of the bedrooms and this had damaged the plaster in these rooms. This was not evident on previous inspections and not reported in the AQAA. A report of a visit by a representative of the provider said that there had been a problem in one bedroom with the pipe work. Long periods of dampness can affect the health of residents. The kitchen was clean and organised. Hot food was probed and records were kept and fridges and freezers were showing appropriate temperatures to maintain good food safety. There was a delivery of food every two weeks from a main supplier sometimes the amount of storage was problematic. Some food supplies are kept in the conservatory. The cook has appropriate food and hygiene training, infection control and cooking certificates. There were appropriate laundry facilities. Not all staff handling food had an in date food hygiene certificate Ashleigh Court DS0000051010.V340968.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The lack of appropriate checks on recruitment and the lack of consistent induction and up date training means that residents could be at risk of poor care. EVIDENCE: Rotas were supplied for July these did not always show which member of staff was undertaking the cooking when the cook was not on duty. The home plans to have 3 care staff on the morning and 2 on the afternoon plus cook, domestic and management hours during the week and at weekends sometimes there are only 2 staff on the morning shifts. The shift patterns include long hours of working 13-hour shifts on occasions. Staff sign to say they will work over 48 hours per week. Two staff are on duty at night. According to the AQAA, over 50 of staff have achieved a National Vocational Qualification (NVQ) level 2 in care, other staff have enrolled on this course. Two staff files looked at had a copy of the NVQ2 as stated. This means that these staff have the knowledge to be able to provide the care for older people. Staff were recruited following completion of an application form, and interview the receipt of references which were checked upon. Staff received job descriptions and contracts that showed that they were expected to work to the Ashleigh Court DS0000051010.V340968.R01.S.doc Version 5.2 Page 21 General Social Care Councils Code of Practice, which helps to ensure that residents are protected. The home had checks done on staff backgrounds before employment but there were gaps. Staff employed from abroad had checks done which included translated references and criminal checks through a recognised agency however they did not have a British Criminal Record Bureau (CRB) or Protection of Vulnerable Adult (PoVA) check as required. Not all CRBs sampled for other staff had the PoVA check done and not all were enhanced checks. Remedial action must be taken. Staff induction processes did not meet the common induction standards set out by the skill for care organisation. We were supplied with a matrix of the amount of training undertaken by the staff team and found the following. Members of the staff team did not attend required training when it was arranged and this was a performance issue, an organisational or funding issue and this must be addressed. There was good compliance with moving and handling training and the majority of staff had first aid training. Ashleigh Court DS0000051010.V340968.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the home is ensuring that residents and relatives are happy with the service the delay in responding to some requirements and gaps in staff recruitment and training mean that residents welfare could be at risk. EVIDENCE: The manager has the experience and the training to be the manager of a care home. The manager has passed her Registered Managers Award since the last key inspection. She also tries to be involved with any training events put on for the staff in the home. Ashleigh Court DS0000051010.V340968.R01.S.doc Version 5.2 Page 23 The home has not got a formal quality assurance mechanism. Representatives of the owners undertake monthly visits to look at how the home is performing. The manager has received four responses to surveys given to residents and a representative. There is no annual report of what the home intends to do in the coming year. The home keeps a float of residents’ money on request to help with the payment of such items as hairdressing and chiropody. Two of the residents’ financial records and money held were checked. The money in held matched the record. One resident was waiting for social services to sort out their money and the home was assisting with this as much as they could. The manager was confident that residents were receiving the benefit of their personal allowance. The home had majority the health and safety certificates of maintenance and inspection of the building that were sampled. The resident call alarm required a service and there was no evidence of a recent thorough examination of the lift (LG1). Improvements needed to be made to the fire drills, training and records. Records did not show learning points after drills or the length of time drill took. Drills took place during the day and they were unable to show that staff had the benefit of a drill six monthly. Not all staff have had updated training on fire safety on a six monthly basis. A resident was receiving oxygen therapy, there was no sign on the door to alert that oxygen was being stored in the room and an oxygen cylinder was not chained to the wall. These measures were needed in case of fire. Previous requirements to have an opening restrictor on the window in the ground floor toilet and for a fridge freezer to be removed from the garden were still outstanding. Ashleigh Court DS0000051010.V340968.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 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 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Ashleigh Court DS0000051010.V340968.R01.S.doc Version 5.2 Page 25 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 OP18 Regulation 13(6) Requirement All staff must receive training on adult abuse awareness. This is to ensure that residents are protected from harm and abuse. The source of the water getting into the building and causing plaster damage must be investigated and the damage put right in all rooms. Timescale for action 30/11/07 2 OP19 23(2)(b) 31/10/07 3 OP24 23(2)(j) 4 OP26 13(3) This is to ensure that residents are not put at risk of infections caused by staying in rooms that have damp areas. Any bedrooms without en-suite 30/09/07 facilities must have a wash hand basin fitted with a supply of hot and cold water. (Previous time scales of 01/04/05, 01/09/05 and 30/11/06 not met) This is to ensure that all residents have the opportunity to be independent in their personal care and have their personal care in an area that is private. All care staff handling food must 30/11/07 DS0000051010.V340968.R01.S.doc Version 5.2 Page 26 Ashleigh Court have a basic food hygiene certificate. This is to ensure that residents are not at risk of gaining a toxic infection from poor food hygiene practices All care staff must have an enhanced Criminal Records Bureau disclosure that includes a protection of Vulnerable Adults check. This must be applied for by 30/08/07 and evidence kept This is to ensure that staff that may cause them harm do not assist residents. There must be evidence on site that the emergency call system is regularly serviced. (Outstanding since 01/01/06 and 31/10/06) This is to ensure that residents can be assured if they use the call alarm it will work. The ground floor toilet must have a window restrictor fitted. (Outstanding since 31/10/06) This is to prevent residents from being harmed going out via this window. The home must ensure adequate fire safety practices by ensuring all staff have training, and opportunity to attend fire drills. This is to ensure that residents have the benefit of well trained and practiced staff in the event of a fire. There must be a thorough examination of the passenger lift to ensure the safety of the residents using it. A copy of the certificate must be retained at the home. DS0000051010.V340968.R01.S.doc 5 OP29 19 sch 2 (7) 30/10/07 6 OP38 23(2)(c) 30/10/07 7 OP38 13(4)(c) 30/09/07 8 OP38 23(4)(d) (e) 30/10/07 9 OP38 23(2)(c) 30/10/07 Ashleigh Court Version 5.2 Page 27 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 OP3 OP7 OP9 Good Practice Recommendations The registered manager must ensure that prospective residents or their representatives receive written confirmation that the home can meet their needs. There should be a care plan for every need identified in the assessment. Medication administration should be improved by ensuring that: A photograph of new residents is put next to the relevant medication Administration record (MAR) in a timely way, A list of how each member of staff initials the MAR is kept, 4 5 6 7 8 OP12 OP16 OP19 OP19 OP29 More staff undertake medication administration training. A wider range of activities and time in the community must be extended to all residents. The home must ensure that the residents views are collect to aid their complaint and audit processes. (Outstanding since 30/11/06) It is strongly recommended that a ramp be installed in the garden area. The home must investigate the raising of the chandelier in the front room. (Previous timescale of 31/10/06 not 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 fridge freezer must be removed from the side of the building. (Outstanding since 31/10/06) An approved sign must be placed on the door where oxygen is stored and oxygen cylinders should be chained to the wall. 9 10 OP38 OP38 Ashleigh Court DS0000051010.V340968.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-56 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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