Inspection on 20/04/05 for Ashleigh House

This inspection was carried out on 20th April 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 House 02/07/07

Ashleigh House 11/10/05

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 3 2 Stonehouse Road Boldmere Sutton Coldfield B73 6LR Lead Inspector Amanda Lyndon Unannounced 20th April 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. 3 E54 S63255 Asleigh House V223704 200405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Ashleigh House Address 2 Stonehouse Road Boldmere Sutton Coldfield West Midlands B73 6LR 0121 354 1409 0121 308 8091 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) Senex Limited Mrs Suzanne Hammond Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places 3 E54 S63255 Asleigh House V223704 200405 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to provide personal care for 13 people for reasons of old age (13 OP) 2. The home must provide a minimum of three members of staff on duty during peak hours when the home is at full occupancy (this may include the manager) 3. This can be reduced pro-rata for reduced occupancy to no less than 2 members of staff, however, the staffing levels must be determined by the dependencies of the service users. Date of last inspection 14th September 2004 Brief Description of the Service: Ashleigh house, formerly a large family home has been extended to provide accommodation for thirteen older people on two floors. It is situated in a predominantely residential area within easy walking distance of local amenities and public transport. The homes category of registration is for older people excluding people in need of care for reasons of dementia, learning disability or other reasons. The home has adaptations including a stair lift to assist access to the first floor however access to the first floor for wheelchair users is restricted. There is a small garden area to the rear of the house for residents use. All bedrooms are for single occupancy and each have an en suite toilet and a wash hand basin. Decoration in the home is of a high standard. There is a spacious lounge and dining room with french doors opening out onto a small patio area. Ample parking is provided to the rear of the home. The home has a non smoking policy throughout. 3 E54 S63255 Asleigh House V223704 200405 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was undertaken by one Inspector during a morning and lunch time period, and was assisted throughout by the home owner. There were twelve residents living at the home on the day of the inspection and the Inspector met with the majority of these people. Information was gathered from speaking with the residents and staff, observing the care staff perform their duties, examining care and medication records and by undertaking a tour of the home. There were no visitors at the home during the inspection. There had not been any changes to the management structure within the home since the previous inspection. All of the residents met during the inspection expressed their satisfaction in respect of the service provided by Ashleigh House. What the service does well: What has improved since the last inspection? Each resident had a care plan describing the care that they require to ensure that the care staff give the appropriate support to meet the person’s care needs. Residents are invited to group meetings to discuss the service provided at the home. 3 E54 S63255 Asleigh House V223704 200405 Stage 4.doc Version 1.20 Page 6 Hand rails have been fitted in all en suite bathrooms as required and hand rails are now available on both sides of corridors making it easier for residents to move safely around the home. An additional assisted bathing facility has been provided on the first floor of the home so people living in this area of the home have a bath suitable for their needs in close proximity to their bedrooms. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 3 E54 S63255 Asleigh House V223704 200405 Stage 4.doc Version 1.20 Page 7 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 3 E54 S63255 Asleigh House V223704 200405 Stage 4.doc Version 1.20 Page 8 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, 3 & 5 Prospective residents are given clear information about the service provided by Ashleigh House and are invited to spend a day at the home in order to sample what life would be like to live there, enabling them to make a choice about whether or not they may wish to live in the home. Residents are accepted to live at Ashleigh House following an assessment to ensure that the home can meet their care needs. EVIDENCE: The statement of purpose and service user guide had been amended since the previous inspection. These included the majority of information required and are also available in large print. Resident’s views were not incorporated into the service user guide. Senior staff undertake pre admission assessments for all people wishing to live at Ashleigh House, in order to ensure that the home can meet their care needs. The pre admission assessment document had been revised since the previous inspection and this included all information required. Prospective residents are invited to spend the day at Ashleigh House and have a meal with other residents to ensure that the home met their expectations, and a 28 day trial period is offered. 3 E54 S63255 Asleigh House V223704 200405 Stage 4.doc Version 1.20 Page 9 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, 9 & 10 Residents are generally well supported by the care staff and multi disciplinary team to ensure that their health and personal care needs are being met. Arrangements for the management of medication is good with clear and comprehensive procedures being in place to ensure residents’ medication needs are met in a safe manner. Residents are generally supported in a respectful manner by the staff working at the home and this ensures that the residents’ dignity and self esteem are maintained. EVIDENCE: Residents were clean and wearing clothing appropriate for the time of the year with the exception of one resident who had very dirty fingernails and this was brought to the attention of the Registered Person. The care staff refer to the residents’ General Practitioner’s and other Health Care Professionals as required for medical advice and to ensure that their health care needs are met. One resident said “ The staff bring me my medication and the Doctor comes to see me when I ask or when arranged by the carer”. Robust systems were in place for the ordering, receiving, administering and storage of medication and appropriate measures were in place for refrigerated medication and controlled drugs. Audit trails of medication stocks undertaken 3 E54 S63255 Asleigh House V223704 200405 Stage 4.doc Version 1.20 Page 10 by the Inspector were found to be correct. One resident had chosen to self administer their own medication and a risk assessment of this had been undertaken and was reviewed regularly. Residents did not have a key for their bedroom door and a record of the reasons for this was not kept. All of the residents had a private telephone line in their bedrooms. Care plans were comprehensive, easy to understand and included the resident’s preferences. Care plans of residents’ specific medical conditions and associated risk assessments had been undertaken and these described the care to be given. Care plans were reviewed regularly. Not all care plans were written and reviewed with the involvement of the resident and/or representative. One resident said “I didn’t know that there was a care plan”. Moving and handling risk assessments were not always completed in full and did not include detail of the action to be taken should a resident fall. The daily reports were generally informative and included some information of the activities that the residents have engaged in during that day. Staff were interacting appropriately and respectfully with residents, however, an infant’s feeder beaker had been purchased by the home for a resident with poor eyesight and this style is not age appropriate and should be replaced with an adult appropriate drinks beaker. The Inspector did note that the same resident had an appropriate lipped plate to promote independence at mealtimes. 3 E54 S63255 Asleigh House V223704 200405 Stage 4.doc Version 1.20 Page 11 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 14 15 Residents receive a wholesome and varied diet which meets any special dietary needs. Residents living at the home are safe and secure and are given choice and freedom to make decisions regarding their daily lives. The home needs to support residents to exercise choice in respect of alternative meals which are available. The current limited activities on offer do not meet the residents’ expectations. EVIDENCE: The preferences of the residents with regard to their daily routines were recorded within their care plans and residents met during the inspection stated that these were respected by the care staff wherever possible. A resident said “I can have a lie in here every day if I want to”. Another resident stated “ I get in to bed when I am ready”. Residents met during the inspection stated that as well as being allowed their freedom whilst living at the home, they enjoyed the level of security that living at Ashleigh House gave them. Residents’ bedrooms contained many personal items and reflected their individual tastes. A record of food eaten by each resident at each meal time was maintained and this identified an alternative to the main meal option, however, one resident stated “ I can’t stand sandwiches but I was given soup and sandwiches last night”. All of the residents met during the inspection stated that the food was very good and the menus identified a wide variety of food. Fresh fruit was 3 E54 S63255 Asleigh House V223704 200405 Stage 4.doc Version 1.20 Page 12 available although at the time of the inspection most of this was over ripe. A residents’ meeting had been held recently to discuss future menus at the home, in order to give the residents an opportunity to put their suggestions forward. The food was well presented on the day of the inspection, residents were not given the option to serve their own portions at the dining table. Special diets are catered for. Dining tables were laid attractively and appropriately. Hot beverages are served throughout the day and in addition, one resident said “ they come in first thing and bring me a cup of tea at 7am and we have a hot drink about 7.30pm”. A record of the limited activities that residents participated in was included within the care plans and this also included the reasons why a resident may have chosen not to participate in a certain activity. These had not been completed during the last two months. The Registered Person stated that plans were in place to arrange a variety of short trips outside of the home. One resident said “ The entertainer made quite a pleasant activity during the afternoon”. Holy Communion is available at the home on a regular basis and a hairdresser visits each week. The size of the television screen in the communal lounge appeared to be too small for all residents in the room to view. One resident said “The best thing about living here is the company” and another resident said “ I have made more friends here than I had at home”. 3 E54 S63255 Asleigh House V223704 200405 Stage 4.doc Version 1.20 Page 13 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) 16 17 18 The home has a satisfactory complaints procedure and this is accessible to the residents and their visitors so they are aware of how to complain should the need arise. EVIDENCE: The home had not recorded any complaints since the previous inspection. The complaints procedure was on display and this had been revised to include all detail required. One resident said “ I would tell anyone if I wasn’t happy about anything. I don’t stand any nonsense, I’m too old for that”. Another resident said “ I’ve lived here two years and never had to complain”. The adult protection policy incorporated Birmingham Multi Agency Guidelines. Postal voting is available for residents wishing to vote in elections or residents can vote in person. An advocacy service had recently been accessed for a resident. 3 E54 S63255 Asleigh House V223704 200405 Stage 4.doc Version 1.20 Page 14 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 24 25 26 The standard of the environment within the home is generally good providing residents with a clean, homely and attractive place to live. There are a number of outstanding health and safety issues in relation to the premises and these pose a risk to residents’ safety. EVIDENCE: Decoration and furnishings and fittings in the home were of a high standard and the home was in a good state of repair both internally and externally. On the day of the inspection the home was found to be generally clean and fresh and the internal temperature was comfortable. Dirty linen had been thrown on the floor outside the lounge posing an infection control and health and safety trip hazard. Hygienic hand washing facilities were available with the exception of the first floor bathroom in which disposable paper hand towels were not available. The first floor of the home is not suitable for residents who use wheelchairs. During the previous inspection unrestricted access to the main road from the 3 E54 S63255 Asleigh House V223704 200405 Stage 4.doc Version 1.20 Page 15 rear garden was identified as a potential risk to residents’ safety and remedial action had not been taken to address this. Plans are in place to build a ramp in order to provide residents with safe access from the patio doors in to the rear garden from the dining room and from a number of residents’ bedrooms. Since the previous inspection, hand rails had been fitted in all en suite bathrooms as required and hand rails were now available on both sides of corridors. Since the previous inspection, an additional assisted bathing facility has been provided on the first floor of the home. The shower within the ground floor bathroom was not suitable for residents to use independently as a step up into the shower tray was required, and the shower chair was not fit for purpose. Risk assessments must be undertaken in respect of these issues and remedial action must be taken to address the shortfalls. Plans are in place for a refurbishment within the kitchen. Not all residents had a lockable storage facility in their bedroom. Decorative radiator guards had been fitted to a number of radiators in order of priority and plans are in place for the programme of this to continue. Windows could be opened further than the recommended health and safety guidelines and remedial action must be taken to address this. A hand washing facility for staff use was not available in the laundry. The washing machine was in good working order however it did not have a sluice cycle facility. Hot water outlet temperatures are recorded weekly to ensure that they do not exceed safe limits. 3 E54 S63255 Asleigh House V223704 200405 Stage 4.doc Version 1.20 Page 16 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 29 30 Since the previous inspection no improvement has been made in respect of the staff recruitment system at the home potentially leaving residents at risk. The staffing levels are adequate to meet the needs of the current residents living at the home. Staff have received appropriate training to ensure that they are competent to perform within their role. EVIDENCE: A new member of staff had commenced employment at Ashleigh House on the morning of the inspection and was found to be working unsupervised without having undertaken a basic health and safety induction. In addition this person had commenced employment at the home prior to the POVA First or criminal records bureau check being cleared. Pre recruitment documentation in respect of this individual was not available at the home on the day of the inspection. An audit of individual staff members’ training needs had not been undertaken Staff had recently undertaken training in confusion in the event of a resident displaying this type of behaviour. Staffing rotas identified that staffing levels are maintained according to the conditions of registration and the Registered Person provides on call support for the person in charge of the shift. The person in charge of the shift was not indicated on the staffing rotas. One resident said “The staff are very good and helpful and they are very obliging”. 3 E54 S63255 Asleigh House V223704 200405 Stage 4.doc Version 1.20 Page 17 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 35 36 38 The systems for resident consultation are good and there is evidence that the residents’ views sought are acted upon. A robust system for the management of residents’ personal allowances is in place. Staff are trained in respect of health and safety issues to ensure that the residents’ safety and welfare is protected. EVIDENCE: The Registered Person has a professional qualification in the management of care services and has many years of experience in caring for older people. Health and safety checks in respect of equipment used at the home are maintained as required. An on going programme of staff statutory training about fire safety, health and safety, moving and handling and infection control is in place. 3 E54 S63255 Asleigh House V223704 200405 Stage 4.doc Version 1.20 Page 18 As noted during the previous inspection, there was only one hand rail fitted to the staircase leading to the basement of the home and a risk assessment in respect of this must be undertaken. The kitchen was clean and adequate food safety measures were in place. Audits of accidents involving residents living at the home are undertaken and this includes comprehensive falls audits. The Registered Person stated that the programme for formal staff supervision and appraisal was up to date however a system for the recording of this had not been developed. A residents meeting had been held recently however not all residents were interested in participating. One resident said “I’m not interested in residents meetings at my age”. Minutes of recent residents’ meetings were available. Resident service satisfaction questionnaires are distributed and this must be further developed to include an annual report about the findings. A formal quality assurance system had not been developed. The system for the management of the residents’ personal allowance included a separate transaction record and wallet for each of the four individuals who have deposited money with the home for safe keeping. Receipts of all personal items purchased are kept and numbered for ease of auditing. The Registered Person stated that family members deal with the financial affairs of many of the residents. 3 E54 S63255 Asleigh House V223704 200405 Stage 4.doc Version 1.20 Page 19 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. Where there is no score against a standard it has not been looked at during this inspection. 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 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 2 15 3 COMPLAINTS AND PROTECTION 2 3 2 x x 2 2 2 STAFFING Standard No Score 27 2 28 x 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 2 x 3 2 x 2 3 E54 S63255 Asleigh House V223704 200405 Stage 4.doc Version 1.20 Page 20 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. 2. Standard OP1 OP7 Timescale for action 5 Residents views must be 20 incorporated in to the service September user guide. 2005 15(1)(2) Care plans must be written and 20 June reviewed with the involvement of 2005 the resident and/or their representative. 13(5) Moving and handling risk 20 June assessments must be completed 2005 in full and include detail of the action to be taken should a resident fall. 12(1) Residents must be supported to 20 April meet their personal care needs 2005 at all times. 12(2) A record of reasons why a 20 July resident may not have a key for 2005 their bedroom door must be kept. 12(4)(a) An age appropriate drinking aid 20 must be purchased for a resident May 2005 with poor eyesight. 16(2)(n) An activities programme must be 01 developed based on the interests July 2005 of and suggestions given by residents living at the home. 16(2)(i) Residents must be made aware 20 of the alternatives to the main April 2005 meal options at each meal time. 13(4)(a)(c Remedial action must be taken 01 ) to restrict residents access to June 2005 E54 S63255 Asleigh House V223704 200405 Stage 4.doc Version 1.20 Page 21 Regulation Requirement 3. OP7 4. 5. OP8 OP10 6. 7. OP10 OP12 8. 9. 3 OP14 OP19 the main road from the rear garden. An action plan of how this is to be achieved must be submitted to CSCI by: (previous timescale of 28 September 2004 not met) Remedial action must be taken to provide residents with safe access from the patio doors in to the rear garden from the dining room and from a number of residents bedrooms 10. OP19 13(4) 30 June 2005 11. OP21 12. 13. OP24 OP25 (previous timescale of 14 October 2004 not met) 13(4) A risk assessment must be undertaken in respect of the suitability of the existing shower facility for the residents use. In addition, a shower chair that is fit for purpose must be available. 23(2)(m) A lockable storage facility must be available in each residents bedroom. 13(4)(a)(c The Registered Person must ) undertake an audit of window restrictors throughout the home and take remedial action in order to ensure that each window can not be opened further than recommended health and safety guidelines. 13(3) 16(2)(j) A handwashing facility for staff use must be provided in the laundry. (Previous timescale of 14 January 2005 not met) Bed linen and clothing for cleaning must be stored appropriately. Disposable paper hand towels must be available in all communal hand wash facilities in 30 June 2005 31 July 2005 31 May 2005 14. OP26 20 May 2005 15. 16. OP26 OP26 13(3) 13(3) 16(2)(j) 20 April 2005 20 April 2005 Page 22 3 E54 S63255 Asleigh House V223704 200405 Stage 4.doc Version 1.20 the home. 17. 18. 19. OP29 19(1) 13(6) The registered person must operate a thorough recruitment procedure ensuring the protection of residents. The registered person must not employ a person to work at the care home unless the information and documents detailed in Schedule 2 have been obtained. (previous timescale of 14 September 2005 not met) The Registered Person received this in the form of an immediate requirement All staff files must be available at the home. All employees must receive a basic health and safety induction prior to commemcing employment at the home. The Registered Person received this in the form of an immediate requirement. All staff must undertake an induction programme within six weeks of commencing employment at the home and a record of this is to be maintained. (previous timescale of 14 December 2004 not met) An annual report of the feedback from the residents service satisfaction questionnaires must be devised and this must be available for the residents to 20 April 2005 OP27 17 The staffing rotas must identify the identitiy of the person in charge of the shift. 20 April 2005 20. 21. OP29 OP30 17,19 18(1)(c )(i) 20 April 2005 20 April 2005 22. OP30 18(1)(c )(i) 31 May 2005 23. OP33 24(1)(2) 01 September 2005 3 E54 S63255 Asleigh House V223704 200405 Stage 4.doc Version 1.20 Page 23 access. A formal quality assurance system is to be developed in order to review the service provided at the home. The registered person must ensure that all staff receive a formal supervision at least six times per year and an annual appraisal and a record of this is to be maintained. (timescale of 14 December 2004 not met) Policies must be reviewed to ensure they meet all current guidelines and include both an issue and review date (this was not assessed on this occasion. previous timescale 14 January 2005) The Registered Person must undertake a assessment of the risk of staff falling whilst using the staircase leading to the basement of the home. 24. OP36 18(2) 01 August 2005 25. OP37 17 01 July 2005 26. OP38 13(4) 01 May 2005 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. 3 Refer to Standard OP7 OP14 OP26 OP30 Good Practice Recommendations It is recommended that resolved care plans are filed separately from existing care plans for ease of access to current active records. It is recommended that residents are encouraged to serve their own portions of food at the dining table. It is recommended that the washing machine is replaced with a sluice cycle model when the current machine fails, or resident’s needs change. It is recommended that an individual training matrix is developed for all staff and that the training records include E54 S63255 Asleigh House V223704 200405 Stage 4.doc Version 1.20 Page 24 the content and duration of each training session, together with an indication of when updated training will be necessary. 3 E54 S63255 Asleigh House V223704 200405 Stage 4.doc Version 1.20 Page 25 Commission for Social Care Inspection 1st Floor Ladywood House 45-56 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 3 E54 S63255 Asleigh House V223704 200405 Stage 4.doc Version 1.20 Page 26 - 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!