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Inspection on 16/08/08 for Ashleigh House Care Home

Also see our care home review for Ashleigh House Care Home for more information

This inspection was carried out on 16th August 2008.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

There was again evidence of promoting the welfare of residents in terms of good relationships between staff and residents with staff listening and consulting with residents. Residents said that the care provided by staff was very friendly and respectful. This provides residents with a feeling of security. The Manager and staff were keen to consider ideas to improve residents quality of life.Residents are consulted about life at the home with residents meetings to meet their choices. Residents said they liked being involved in the running of the home. Relatives are involved in meetings so that relatives can put forward informed suggestions to improve residents quality of life. Activities are provided as per residents preferences so that residents have opportunities for various activities, which they said they enjoyed. A resident has held a religious service for other residents and this is to be held at monthly intervals to assist residents in observing their religious practices. Two choices are usually offered for lunch every day. Residents said that if they did not like something they could have something else. Staff are encouraged to have training to equip them to meet residents needs and also have supervision to support them in their jobs.

What has improved since the last inspection?

Care plans have been developed to identify the needs of the resident, and set out how the person`s needs are met, which means the residents should always get the care they need. A programme of activities, including visits outside the home, is provided to meet residents preferences to support their well being. Staff recruitment procedures have been improved with records containing evidence of competence, previous employment history, health, identity and eligibility to work with vulnerable people so that residents have staff that can keep them safe. The Annual Quality Assessment Report was provided to the Commission for Social Care Inspection to enable an assessment of the home`s working methods to produce a good quality of life for residents. A programme of maintenance has been commenced, to make sure the home is fit for purpose, kept in a good state of repair and decoration, to provide the residents a pleasant environment to help with their well-being.

CARE HOMES FOR OLDER PEOPLE Ashleigh House Care Home 18-20 Devon Drive Sherwood Nottingham NG5 2EN Lead Inspector Keith Charlton Unannounced Inspection 16th August 2008 09:30 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 House Care Home DS0000002188.V370096.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 House Care Home DS0000002188.V370096.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashleigh House Care Home Address 18-20 Devon Drive Sherwood Nottingham NG5 2EN 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) 0115 969 1165 Mr William Scott Vacant Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Ashleigh House Care Home DS0000002188.V370096.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: - Date of last inspection 18th March 2008 Brief Description of the Service: Ashleigh House is a care home providing personal care and accommodation for 19 older people. The home is owned by William Scott, which is run as a family business. The home is located in a residential area of Sherwood, close to shops, pubs, the post office and other amenities. Opened in 1987 it consists of 2 converted terraced houses with a purpose built extension. Fifteen of the homes bedrooms are single. None of the bedrooms have en-suite facilities. Bedrooms are located on 3 floors and there is a passenger lift. The home has a small, enclosed garden and a small car park. The fees for the service are £330 per week – this information was provided by the Acting Manager on the day of the inspection. There are additional charges for hairdressing and chiropody. Further information about the home is available from the Acting Manager. A copy of the latest inspection report is available in the office. Ashleigh House Care Home DS0000002188.V370096.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience ADEQUATE quality outcomes. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for residents and their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting three residents and tracking the care they receive through looking at their records, discussion, where possible, with them, and care staff and observation of care practices. This was an unannounced Inspection and was undertaken following the poor outcomes for residents from the last inspection in March 2008. The Acting Manager was present and helped in carrying out the inspection. Planning for the Inspection included looking at the Annual Quality Assurance Assessment completed by the Acting Manager which describes how services are provided by the home, notifications of significant events sent to the Commission for Social Care Inspection and the issues contained in the previous Inspection Report. There have not been any formal complaints to the Commission for Social Care Inspection about the service since the last inspection. We were at the home for 7 hours, and the visit included a selected tour of the building, inspection of records and indirect observation of care practices. The Inspector spoke with eight residents, two members of staff, one relative and the Acting Manager. What the service does well: There was again evidence of promoting the welfare of residents in terms of good relationships between staff and residents with staff listening and consulting with residents. Residents said that the care provided by staff was very friendly and respectful. This provides residents with a feeling of security. The Manager and staff were keen to consider ideas to improve residents quality of life. Ashleigh House Care Home DS0000002188.V370096.R01.S.doc Version 5.2 Page 6 Residents are consulted about life at the home with residents meetings to meet their choices. Residents said they liked being involved in the running of the home. Relatives are involved in meetings so that relatives can put forward informed suggestions to improve residents quality of life. Activities are provided as per residents preferences so that residents have opportunities for various activities, which they said they enjoyed. A resident has held a religious service for other residents and this is to be held at monthly intervals to assist residents in observing their religious practices. Two choices are usually offered for lunch every day. Residents said that if they did not like something they could have something else. Staff are encouraged to have training to equip them to meet residents needs and also have supervision to support them in their jobs. What has improved since the last inspection? What they could do better: All prospective residents need to have a full pre-admission assessment to provide information so that the home can meet all the physical, mental, spiritual and cultural needs of the person, so as to enable staff working at the home to be competent to meet those needs. Ashleigh House Care Home DS0000002188.V370096.R01.S.doc Version 5.2 Page 7 The care plans must be regularly reviewed, with input from the resident, where possible, so any changes in condition, preferences or wishes are put into the care plan to provide ongoing relevant support for the resident. This includes gaining knowledge of all the residents cultural needs in respect of food, religion etc. Staff need to read all the Care Plans to make sure they can meet residents needs. Food stocks need to be maintained so that the food supply for all foods does not run out and that a choice of main meal is provided every day so that residents can have a choice. The Complaints Procedure needs to be amended to make it easier for residents and others to make a complaint. Facilities must be properly maintained so that they are not out of order due to delays in repair, the programme of décor needs to continue and all areas of the home need to be kept odour free to provide a pleasant environment for residents. Staffing levels for domestic hours needs to be reviewed to ensure that domestic help is sufficient at all times to make sure the home is a clean and comfortable place for residents. Staff on night duty must be fully trained to be able to carry out care duties and staff training needs to be fully put into place to equip staff to meet all residents needs. Recruitment procedures must be fully followed, with records containing two written references before staff commence work in order to fully protect vulnerable people. Health and safety must be fully adhered to in respect of having Risk Assessments for safe working practices, ensuring full fire safety, that there is a schedule of kitchen cleaning in place and that hot water temperatures are controlled to ensure that residents are fully protected from health and safety issues. 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 House Care Home DS0000002188.V370096.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 House Care Home DS0000002188.V370096.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): 3,6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are not fully assessed prior to admission to ensure the home is suitable for them and therefore meet their needs are not completely met. EVIDENCE: Residents said that there was the opportunity to see someone from the home before admission to discuss their needs and they were encouraged to visit. This was backed up in a statement in the home’s Annual Quality Assurance Assessment. Ashleigh House Care Home DS0000002188.V370096.R01.S.doc Version 5.2 Page 10 An assessment was inspected and it contained detail of relevant information as to residents needs, which helps to ensure that all the care needs of residents is covered from day one of their admission. However the form for the most recently admitted person was not fully filled in (no mention of sight, hearing, dietary needs and preferences, behaviour etc), so not all needs were recorded. It was not signed or dated. The outcome of this means that residents may not have their needs met in relation to sight, hearing, food etc met. The Acting Manager said in the Annual Quality Assurance Assessment that assessments are carried out for all prospective residents and that people are invited to the home to have a look around and see if it suits their needs. The home does not offer intermediate care facilities for residents who want to receive rehabilitation before returning home. Ashleigh House Care Home DS0000002188.V370096.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. Residents health needs are not always met which could compromise their well being.. Medication is suitably managed so as to protect the safety and welfare of residents. EVIDENCE: Residents spoken with said that they did not know what Care Plans were, though there was evidence on file that they had signed to agree to them. ‘’I have never seen a Care Plan. I am not that bothered. They seem to do all I need’’. Care Plans seen by the inspector contained a good amount of information as to the physical, social and medical needs of residents – e.g. recording of moving and handling needs, weight, pressure sore assessment, falls risk assessment, Ashleigh House Care Home DS0000002188.V370096.R01.S.doc Version 5.2 Page 12 continence etc. However the needs of residents from different cultures were not fully noted in relation to religion and food. Risk assessments were found to be a part of the plans so that staff know how to keep residents safe. Residents personal histories were noted on plans. The Manager said she was planning to make this more detailed in the near future so that residents can be seen more fully as individuals with a valued history. Monthly reviews of residents needs were noted in Care Plans though were not up to date, which is needed to ensure that care is fully relevant to the individual resident. Staff said they had not read all the Care Plans. The Manager said she would ensure that this is carried out. One staff said that a resident needed to lie on his bedroom floor to feel safe (issues from the past) but the Care Plan did not mention this so it could alarm new staff who could then act inappropriately not realising this was something of comfort to him. Residents said when they felt ill then staff would swiftly summon medical assistance – residents contacts with medical personnel were documented in their Care Plans. Accident records were viewed which showed that medical services were not always properly contacted on an occasion when there had been a potentially serious injury, e.g. head injury - instance of a fall in November 2007, which was not referred to Medical Services. The Manager said this issue would be followed up. The inspector observed that staff were friendly and respectful to residents and encouraged in a friendly manner at the residents pace. Two staff were observed to follow proper Moving and Handling procedures and ensuring that the resident was safely sitting in a comfortable position in her chair with a pressure cushion in place. Residents said that staff respected their privacy and knocked on doors before they entered and the inspector also saw this happened. The Manager and staff confirmed that all staff that issue medication had undertaken medication training and this was recorded on staff records. Staff and the manager said that some staff were in the middle of completing their medication training. Medication was observed to be properly given by staff and signed. Medication record sheets were found to be well completed with only a small number of gaps noted, as staff had not signed to state that medication had been given to residents on these occasions. Medication had been properly signed in when received. There were photos on medication sheets to help identify residents and prevent mistakes being made. Medication was kept fully secured. Ashleigh House Care Home DS0000002188.V370096.R01.S.doc Version 5.2 Page 13 The policy of the home, as stated in the Annual Quality Assurance Assessment, is that residents can handle their own medication if they are safe to do so and choose to do so. A resident spoken with appreciated that he could do this but liked staff to do it for him. Ashleigh House Care Home DS0000002188.V370096.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 good. This judgement has been made using available evidence including a visit to this service. Daily life and social activities at Ashleigh satisfy residents’ social, cultural, religious and recreational interests, needs and choices. Residents living at the home have a opportunities for activities of their choice. EVIDENCE: Residents said that they were generally very satisfied with the range of activities on offer. ‘’There’s things going on like quizzes and bingo. There is something to do every day if you are interested’’. ‘’We get to go out now. There was an outing to Skegness last month and the manager is looking into another day trip’’. ‘’Staff bring me books. They are good like that’’. The minutes of Residents Meetings supported the home’s emphasis on activities and an Activity folder is kept showing what has taken place. Ashleigh House Care Home DS0000002188.V370096.R01.S.doc Version 5.2 Page 15 A resident has taken a sevice for other residents which the Manager said they enjoyed and this is to be held monthly. The Manager has introduced a quarterly newletter for residents to provide more information to residents about the range of activities on offer. Residents said if they wanted to go out then staff would take them for a walk. One resident said she liked sitting in the garden when the weather was good and there were new plants there now which she enjoyed looking at. A resident said that he could go out whenever he wanted. Another resident was seen coming back from a trip out, thereby confirming that residents have choice and independence. A record of residents meetings was seen, which the manager said is to happen regularly. Relatives are also invited to meetings to inform management as to how the home can continually promote the quality of life for residents. Residents said that their visitors were made welcome by staff and this was supported by staff comments. Residents said there were no rules, e.g. going to bed and getting up times, being able to have alcohol and smoke in the designated lounge, whether to stay in their rooms or go to the lounge etc, and staff respected this. Staff said that it was important that residents were able to keep their independence so they could still do things for themselves. This was confirmed by comments made by residents. Residents again said that they thought the food was good or mainly good. ‘’The food is pretty good. We get a choice’’. ‘’I think that the food is nice. They ask about it at the meeting what we think of it’’. ‘’ Portion sizes could be bigger, I would like seconds and there are too many sandwiches. Fruit is not freely available’’ – the Manager queried the validity of these comments but said they would be followed up and put in place as necessary. Residents said there was usually a choice each day for the main meals and residents knew they could ask for something else if they did not want the meal on offer. Residents food preferences were recorded in their Care Plans though this was not recorded in detail for the resident from a minority culture. Staff and the Manager said that a relevant cookbook would be ordered to show the resident to see if this food was wanted. The lunch was served at different times to enable residents choices. Ashleigh House Care Home DS0000002188.V370096.R01.S.doc Version 5.2 Page 16 The inspector noted low food stocks, including only carrots and swede as vegetables. The Manager showed him invoices regarding food that had been ordered and was to be delivered early the next week. Ashleigh House Care Home DS0000002188.V370096.R01.S.doc Version 5.2 Page 17 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 good. This judgement has been made using available evidence including a visit to this service. Residents feel able to talk to staff about any concerns they might have and staff are trained to safeguard adults so people are safe and protected. EVIDENCE: Residents spoken with thought that if there was a problem then they thought the management would sort it out: ’’I am sure they would do something’’. ‘’I never need to complain’’. Complaints records are kept. There have been no complaints since the manager took over earlier this year. The Complaints Procedure is different depending on which document is looked at and does not give the complainant the option to go to the lead Agency, the local Social Service Department, at the start of the complaint. The Manager said these issues would be followed up. Ashleigh House Care Home DS0000002188.V370096.R01.S.doc Version 5.2 Page 18 Staff members spoken with were aware of the procedure and the Agencies to contact if the in house arrangement failed, if abuse was witnessed or suspected. Ashleigh House Care Home DS0000002188.V370096.R01.S.doc Version 5.2 Page 19 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. Residents live in an environment that is to their liking but odour control needs to be improved. EVIDENCE: Residents said that they generally liked the facilities of the home, and they could organise their bedrooms in the way they wanted. During a selective tour of the home it was observed that some areas have been decorated since the last inspection and this was continuing. Some furniture is worn and chipped. Rooms had been personalised to accommodate personal possessions. Ashleigh House Care Home DS0000002188.V370096.R01.S.doc Version 5.2 Page 20 There were incontinence pads stacked on an easy chair, which detracted from the homely appearance. Residents all said that they liked their bedrooms and they could bring in their own things. These were observed to be personalised and generally homely by the inspector, with personal items of furniture, pictures, photographs etc. One resident was able to bring in his fridge. ‘’My bedroom is nice and clean and I can have all my things in it’’. ‘’They are decorating more of it in the future’’. The lounges appeared comfortable though there was a comment by staff that they needed to be furnished in a more homely fashion with having some raised sofas, and some of the woodwork and carpets were too dark, making it look ‘dingy’ in some parts. The Registered Manager said that some décor had been done and there were plans to complete the redecorate of further areas and this would be finished by the end of the year. A bathroom was found to be out of order. Another bathroom had an old chair in it and a broken shower, no toilet roll holder and no towels. A bedroom was found by the inspector to be very warm even though the radiator was not on. The Manager said these issues would be followed up. There is a step to the dining room, which the inspector saw a resident trying to climb with some difficulty and it looked a potential trip hazard. This needs to be risk assessed. There is currently signing to the environment to assist with residents to find their own rooms and is helpful to residents with dementia, i.e. photos on doors to make them more recognisable. Odour control was of a satisfactory standard generally apart from a corridor area and bedroom, which had a strong malodour. Ashleigh House Care Home DS0000002188.V370096.R01.S.doc Version 5.2 Page 21 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 adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels for domestic hours may be insufficient to ensure the home is kept fresh. Recruitment procedures are not fully in place to properly protect residents welfare. Staff training systems are in place to plan to equip staff to meet residents needs. EVIDENCE: Residents were positive about the staff: ‘’Staff are very friendly and are very busy’’. ‘’If I need them they come very quickly’’. The staffing rota for the main home demonstrated that that there are three care staff on duty along with the Manager and one waking staff at night with a sleeping in staff as back up. Staffing levels have increased since the last inspection. Ashleigh House Care Home DS0000002188.V370096.R01.S.doc Version 5.2 Page 22 The sleeping in staff is the domestic but there was no evidence of training in relevant care issues – the Manager said she recognised this and it would be provided. There is domestic cover six days a week, for a three hour period, which means that if there are any accidents then care staff have to deal with these, taking them away from care work. The Manager said that there was mandatory training for staff on a range of essential care issues – e.g. food hygiene, health and safety, fire, first aid, moving and handling, infection control, dementia etc and this was reflected in the Training Matrix displayed on the office wall, though there were a number of gaps where staff had not yet had training – e.g. only two staff had challenging behaviour training and only four staff had had training in infection control and health and safety. There was evidence of induction training for new staff – the Manager said that the recognised Skills for Care induction pack was to be used for new staff. Specific training on residents conditions – e.g. stroke care, diabetes, parkinsons disease, hearing and visual impairment etc, is still needed. The Registered Manager said she would add these topics to the Training Matrix and this will be carried out in the coming months. Staff said they were encouraged to undertake National Vocational Qualification level training. The Annual Quality Assurance Assessment stated that all staff have completed the National Vocational Qualification level 2 training, which exceeds the National Minimum Standard. Recruitment records were reviewed these need to be more robust to ensure that there is a proper check of competency etc so that residents receive a good service. The Manager said this would be followed up. Ashleigh House Care Home DS0000002188.V370096.R01.S.doc Version 5.2 Page 23 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. Management systems need to be tightened up to ensure the complete health and safety of residents. EVIDENCE: Residents and staff said that they thought the home ran well and the manager was approachable if they needed to ask anything. Staff said they felt valued in their work by the management of the home. ‘’The home runs well’’. ‘’It is run in a friendly way’’. Ashleigh House Care Home DS0000002188.V370096.R01.S.doc Version 5.2 Page 24 The Manager has a National Vocational Qualification level 4 and a Registered Managers Award training and has had years of experience in working in care homes. There was evidence on records that staff are supervised and supported. Staff also said this was the case. There are now Residents Meetings to ensure that there is a forum to air views and preferences, put forward suggestions etc so that residents feel they have an input into the running of the home. A Staff Meeting has been held and recorded which proved that staff can discuss care issues in order to produce high standards to benefit residents. A Quality Assurance system was in place to review services and the Manager is in process of changing this to a more detailed system and then do an analysis of questionnaires to ask residents and relatives about services on a yearly basis. They are not given to other interested parties - e.g. GPs, Social Workers, District Nurses etc., and the results are not in the Statement of Purpose, so that this information is available to residents and their representatives. Residents monies records were found to be properly kept with running balances and two signatures recorded to show that transactions are witnessed, with receipts available to prove that the home was keeping monies correctly. Control of Substances Hazardous to Health assessments were found to be in place. There was no letter from the Environmental Health Officer to confirm that the Requirements from the 30/5/08 Report had been complied with. Food was found in the fridge undated and vegetables were stored on the store floor, contrary to good Food Hygiene practice. The Manager said this would be followed up. A cleaning schedule for the kitchen needs to be in place to ensure Food Hygiene practices are adhered to. There were no Risk Assessments of safe working practices available – these are required to ensure residents and staff are protected from any identified hazards. Fire Precautions: weekly fire bell testing was carried out and fire drills are carried out on a basis of at least every six months. There was also a fire risk assessment on file, which helps to ensure that proper fire safety systems are in place to protect residents. Fire extinguishers had been serviced in the past year. Ashleigh House Care Home DS0000002188.V370096.R01.S.doc Version 5.2 Page 25 System testing was not on the required monthly schedules for emergency lighting. Fire doors were seen to be wedged open around the home though many doors had approved fire closures on them. An Immediate Requirements Notice was served to deal with this issue. A bedroom fire door also could not shut on its rebate, which meant the resident was not fully protected if a fire occurred. Hot water temperatures were tested by the inspector and found to be 46.8c in a bathroom - not meeting the National Minimum Standard of close to 43c to ensure that residents are protected from scalding water, despite a regular test being in place. An Immediate Requirements Notice was served to deal with these issues, which the Manager said would be dealt with. Ashleigh House Care Home DS0000002188.V370096.R01.S.doc Version 5.2 Page 26 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 X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 1 X X X X X X 1 STAFFING Standard No Score 27 2 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Ashleigh House Care Home DS0000002188.V370096.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No 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 OP19 Regulation 23 Requirement The Registered Provider needs to complete the refurbishment programme regarding décor and furniture replacement and ensure that maintenance to facilities is promptly carried out to ensure residents live in a homely environment that meets their needs. The premises must be kept odour free to ensure residents live in a pleasant environment. Timescale for action 16/12/08 2. OP26 23 17/08/08 3. OP38 13 Residents health and safety must 16/09/08 be protected fully at all times regarding fire safety, hot water temperatures, risk assessments for safe working practices and kitchen food hygiene practices being in place. Staff training needs to be provided to meet all the residents needs. 16/02/09 4. OP30 18 Ashleigh House Care Home DS0000002188.V370096.R01.S.doc Version 5.2 Page 28 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. Refer to Standard OP15 Good Practice Recommendations Food choices for all residents need to be fully supplied, good stocks of food kept and that detailed food records kept to evidence choice supplied to residents. It is recommended that the Registered Provider level the dining room floor so that there is not a trip hazard for residents. That domestic staffing cover is reviewed to ensure that the home is always clean and up to standard and that the domestic worker is not covering at night unless trained and able to meet the care needs of residents. 2. OP19 3. OP27 Ashleigh House Care Home DS0000002188.V370096.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. Extracts may not be used or reproduced without the express permission of CSCI Ashleigh House Care Home DS0000002188.V370096.R01.S.doc Version 5.2 Page 30 - 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. 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