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Inspection on 04/08/09 for Ashleigh House Care Home

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

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

The home ensures that pre- admission assessments are carried out on all new and potential people to be accommodated at the home, with only those whose needs that can be met being admitted to the home. The health needs of people who use the service are well met with evidence of good multi disciplinary working taking place. Activities and social/community contact are arranged according to the choice of the person accommodated. Mealtimes are unhurried and all meals are home cooked. There is an efficient complaints procedure in place and the homes processes and staff training should protect individuals in the event of an allegation of abuse. The home has a staff team that have the necessary skills and experience to the meet the needs of the current people accommodated. The management and administration of the home is good, with evidence of consideration being given to the opinions of the people who use the service and/or their relatives/representatives.Ashleigh House Care HomeDS0000002188.V376620.R01.S.docVersion 5.2

What has improved since the last inspection?

What the care home could do better:

Urgent action is required to ensure that medication fridge temperatures are recorded on a daily basis, in order to ensure that medication efficacy is maintained by being stored in an appropriate manner. Urgent action is also required to ensure that advice is sought from an appropriate authority with regards to safe and hygienic sluicing practices in the absence of a sluicing washing machine, in order that the risk of cross contamination is reduced. The shower room on the ground floor must be redecorated and made fit for purpose, in order to further enhance a homely environment. In order to remove the risk of cross contamination an appropriate washing machine with a sluicing facility must be installed. Staff files must be updated to include all items specified by the regulations and the associated schedules, in order to improve recruitment procedures and further safeguard the people who use the service. All staff who administer medication must receive up to date training in medication procedures, in order to further safeguard the people who use the service from risk of medication errors.Ashleigh House Care HomeDS0000002188.V376620.R01.S.doc Version 5.2 It is recommended good practice that the pre admission assessment is updated to include information of where the assessment took place and that all pages of the care plan are named for the individual that they relate to. In view of the comments made by the people who use the service and staff and from observations made at the inspection the refurbishment programme should continue to ensure that people live in a comfortable and homely environment.NB: Since the inspection was conducted the Registered Manager has written to the CSCI, confirming that all Immediate Requirements and Requirements relating to staff files and sluicing facilities have now been actioned.

Key inspection report CARE HOMES FOR OLDER PEOPLE Ashleigh House Care Home 18-20 Devon Drive Sherwood Nottingham NG5 2EN Lead Inspector Rebecca Shewan Key Unannounced Inspection 4th August 2009 09:30 DS0000002188.V376620.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Ashleigh House Care Home DS0000002188.V376620.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Ashleigh House Care Home DS0000002188.V376620.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 Mrs Eileen Joyce Hester 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.V376620.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th August 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 two converted terraced houses with a purpose built extension. Fifteen of the homes bedrooms are single occupancy. One of the bedrooms has en-suite facilities. Bedrooms are located over three floors, with a passenger lift making each floor accessible. The home has a small, enclosed garden and a small car park. The fees for the service are £326 per week with additional charges made for hairdressing and chiropody. Potential new people find out about the service via the internet, CQC reports, by contacting the home direct, by Placing Authorities and Health/ Social Care Professionals. Ashleigh House Care Home DS0000002188.V376620.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 2 star. This means the people who use this service experience good quality outcomes. This unannounced inspection took place during the morning and afternoon of the 4th August 2009. Incident reports and the homes Annual Quality Assurance Assessment (AQAA), held by the Care Quality Commission, were read before the inspection. The inspection of the home took seven hours. A tour of the whole home was undertaken and the Registered Manager, two staff and two people who use the service, were spoken with. Records such as care plans, staff files and medication records were also viewed. Seventeen people were accommodated at the home at the time of the inspection. What the service does well: The home ensures that pre- admission assessments are carried out on all new and potential people to be accommodated at the home, with only those whose needs that can be met being admitted to the home. The health needs of people who use the service are well met with evidence of good multi disciplinary working taking place. Activities and social/community contact are arranged according to the choice of the person accommodated. Mealtimes are unhurried and all meals are home cooked. There is an efficient complaints procedure in place and the homes processes and staff training should protect individuals in the event of an allegation of abuse. The home has a staff team that have the necessary skills and experience to the meet the needs of the current people accommodated. The management and administration of the home is good, with evidence of consideration being given to the opinions of the people who use the service and/or their relatives/representatives. Ashleigh House Care Home DS0000002188.V376620.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Urgent action is required to ensure that medication fridge temperatures are recorded on a daily basis, in order to ensure that medication efficacy is maintained by being stored in an appropriate manner. Urgent action is also required to ensure that advice is sought from an appropriate authority with regards to safe and hygienic sluicing practices in the absence of a sluicing washing machine, in order that the risk of cross contamination is reduced. The shower room on the ground floor must be redecorated and made fit for purpose, in order to further enhance a homely environment. In order to remove the risk of cross contamination an appropriate washing machine with a sluicing facility must be installed. Staff files must be updated to include all items specified by the regulations and the associated schedules, in order to improve recruitment procedures and further safeguard the people who use the service. All staff who administer medication must receive up to date training in medication procedures, in order to further safeguard the people who use the service from risk of medication errors. Ashleigh House Care Home DS0000002188.V376620.R01.S.doc Version 5.2 Page 7 It is recommended good practice that the pre admission assessment is updated to include information of where the assessment took place and that all pages of the care plan are named for the individual that they relate to. In view of the comments made by the people who use the service and staff and from observations made at the inspection the refurbishment programme should continue to ensure that people live in a comfortable and homely environment. NB: Since the inspection was conducted the Registered Manager has written to the CSCI, confirming that all Immediate Requirements and Requirements relating to staff files and sluicing facilities have now been actioned. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Ashleigh House Care Home DS0000002188.V376620.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.V376620.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has processes in place for assessing potential new people with services being offered to only those individual’s whose needs can be met. EVIDENCE: From the records viewed we observed that the home’s Registered Manager carries out pre- admission assessments. We observed that copies of care management assessments from the placing authority are obtained, where these exist. The Registered Manager reported that she addresses any issues, which are highlighted within this assessment. We observed that documented records are maintained of all correspondence with the placing authority. Records inspected showed that pre- admission assessments are carried out on all new and potential people. Documentation relating to the most recent Ashleigh House Care Home DS0000002188.V376620.R01.S.doc Version 5.2 Page 10 admissions to home were viewed and found to have been completed fully and conducted with the involvement of the individual and/or their representatives (where applicable). We observed that pre admission assessments do not current provide information as to where the assessment was conducted. Intermediate care is not provided by this home. Ashleigh House Care Home DS0000002188.V376620.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are offered a good provision of health care and personal support by the home. All care is administered in way that protects the privacy and dignity of the people who use the service. Medication procedures ensure that medication are stored and administered safely. EVIDENCE: Care plans and risk assessments were sampled and it was evidenced that these were in need of updating to be more comprehensive and reflective of the needs of the person using the service. Discussions with the Registered Manager highlighted that the current care plan system is being updated and a Ashleigh House Care Home DS0000002188.V376620.R01.S.doc Version 5.2 Page 12 new format is being introduced. The Registered Manager reported that all care plans will be completed in this format by September 2009. We observed a new care plan which had been completed and it was evident that the new format (which is written word and pictorial) is written to allow the assessor to gain a good overview of individuals medical, mental health, social and personal care needs and provide the assessor with a clear overview of the individuals needs, limitations assessed risks and required assistance. The new format will need amending further to ensure that all pages are named for the individual that they relate to. We observed that people who use the service are involved in the care plan review process. Care plans are reviewed on a monthly basis and are updated to accurately reflect any change in needs. From records viewed and discussions with the Registered Manager, we observed that: People who use the service are registered with one of two local Health practices and have access to seven GP’s. District Nurses, provide continence advice and attend the home as needed and are accessed directly by the staff of the home. Domiciliary Opticians attend the home and private appointments to local opticians are also supported. Access to physiotherapy, Occupational Therapy and the Dietician are sourced via the GP. Audiology appointments are arranged via The Ropewalk centre, based in the centre of Nottingham City. The home has a Chiropodist who attends the home every six weeks and as required. The home has good links to the Community Mental Health Team. We observed that the home has good procedures in place for the monitoring and recording of all drugs administered and those entering and leaving the home. We viewed the stores for medication and these were found to be maintained in a clean and orderly manner. Records of medication fridge temperatures were viewed and we observed that these had not been recorded since May 2009. Therefore an Immediate Requirement was made. We also observed that the medication trolley keys were kept in the medication trolley. An Immediate Requirement was made and this was discussed with the Registered Manager. The keys were removed and were held by a member of staff trained in medication procedures. We observed staff providing personal support to people who use the service in such a way that promoted and protected their privacy and dignity. It was observed that individuals bedroom doors were knocked before staff entered them and that the people who use the service were called by their preferred choice of address. Ashleigh House Care Home DS0000002188.V376620.R01.S.doc Version 5.2 Page 13 People who use the service and staff surveyed commented: ‘treat us with respect and give us a choice’, ‘care for me, give me what I want’, ‘Cares and puts residents first in every which way’ and ‘Provides care and respect and dignity to all service users’. Ashleigh House Care Home DS0000002188.V376620.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a wide range of social, cultural and recreational facilities for the people who use the service, allowing for the choice and wishes of individuals who use the service to be respected. EVIDENCE: We observed that under the new care plan system people who use the service have been consulted regarding their social and leisure interests. The Registered Manager reported that there is not a published list of activities in place, this is at the request of the people who use the service of prefer to choose activities on a daily basis. We observed that records are maintained of all activities attended by individuals and whether they enjoyed them or not. We observed from records and from discussions with the Registered Manager that Holy Communion is provided for the people accommodated. The Registered Manager reported that individuals are supported to attend the local church on a weekly basis. Ashleigh House Care Home DS0000002188.V376620.R01.S.doc Version 5.2 Page 15 We observed that outings such as trips to Sherwood Forest, Shopping both local shops and city centre, Skegness take place. The Registered Manager reported that a trip has been planned to go to take individuals to Matlock. From records viewed and discussions with people who use the service, we observed that contact with family and friends is positively encouraged, with visitors being able to attend the home at any time and in accordance with the individual’s wishes. We observed that menus are planned with residents input. The Cook reported that menus are devised on a daily basis and that all meals are home cooked with an alternative option available for each mealtime. We observed that meals can be taken in the individuals bedroom or in the communal dining room. We observed that medical, therapeutic or religious diets are provided as needed. We observed that there is a system in place for drinks and snacks to be available at all times. We observed that the meal served during the inspection was ample in quantity and attractively presented. The lunchtime meal was observed to be unhurried. Records of daily menus taken were observed and we noted that they offered a good variety. Ashleigh House Care Home DS0000002188.V376620.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service benefit from a robust and efficient complaints procedure, whilst the homes procedures, processes and staff training should protect individual’s in the event of an allegation of abuse. EVIDENCE: We observed that the home has an established complaints procedure in place. The homes AQAA provided evidence that the home has received one complaint in the past twelve months. People who use the service that were spoken with and survey responses, highlighted that they would know how and who to complain to. From staff files viewed we observed that both Criminal Records Bureau (CRB) and Protection of Vulnerable Adult (POVA) checks are carried out on all new and existing staff. Training records confirmed that staff have attended training in the Safeguarding of Vulnerable Adults within the last twelve months. The Registered Manager reported that she has achieved the status of ‘Train the Trainer’ in the Safeguarding of Vulnerable Adults and the Mental Capacity Act. Records sent to the CQC confirmed that there has been one Safeguarding Alerts raised by the home in last twelve months. This matter has subsequently Ashleigh House Care Home DS0000002188.V376620.R01.S.doc Version 5.2 Page 17 been resolved and all actions required to protect the individuals involved were taken by the Registered Manager and the staff team. Ashleigh House Care Home DS0000002188.V376620.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21 & 26 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides accommodation for the people who use the service that is suitable for its purpose. EVIDENCE: From the tour of the premises we observed that the location and layout of the home are suitable for its stated purpose. Discussions with the Registered Manager and from documentation viewed we noted that the home has an ongoing plan of refurbishment in place. During the tour of the premises we observed that areas of the home undergone redecoration. We observed that a number of key areas require refurbishment in particular the shower room on the ground floor. This room Ashleigh House Care Home DS0000002188.V376620.R01.S.doc Version 5.2 Page 19 was observed to have peeling wall paper, unclean tiles and was generally maintained in a poor manner. Surveys completed by staff and by people who use the service, included comments; ‘It could be updated – more modern furnishing and carpets’, ‘The home could do with a little bit of TLC (Decorating etc)’, ‘Have the home decorated with bright colours’ and ‘Better laundry system (individual washing) and better decorating’. Therefore the previous inspection Recommendation that the refurbishment programme should continue to ensure that people live in a comfortable and homely environment remains in place. We observed that there were a number of fire hazards within the home, in that the boiler room was being used to dry laundry and that the linen room was being used a place to leave waste such as old furniture, clothing and mattresses. We also observed that unnamed bath products and toilet cleaner were found in a number of bathroom and toilet areas. Therefore Immediate Requirements were made. On the day of the inspection a second tour of the premises was conducted and it was observed that the boiler room had all linen and clothes lines removed, the linen room had been cleared, with all waste having been removed and all chemical products or unnamed bath products had been stored appropriately. From records viewed we evidenced that there is a system in place to ensure that water temperatures are kept within safe levels. We observed that the home has an infection control policy in place and staff are trained in infection control procedures, staff training records viewed confirmed this. We evidenced that there is a daily cleaning schedule in place. Observations of the laundry room provided evidence that care staff hand sluice soiled laundry. Discussions with the Registered Manager and a Senior Carer highlighted that soiled laundry does not occur very often, however care files and daily records viewed provided evidence that there had been two episodes of soiled linen in a week’s period. Care staff spoken with confirmed that they sluice by hand. The infection control implications of hand sluicing were discussed with the Registered Manager. Therefore an Immediate Requirement was made. Ashleigh House Care Home DS0000002188.V376620.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a staff team that have the necessary skills and experience to the meet the needs of the people who use the service. EVIDENCE: We observed that there is a staff rota in place, which details staff hours of working and job designations. Discussions with the Registered Manager highlighted 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 people who use the service. From records viewed we observed that the home has a permanent staff team of the Registered Manager, two Senior Carers, five care staff, one cook and one Kitchen Assistant/ Night Carer (whom the Registered Manager reports is trained to conduct both roles). From the training records viewed we observed that seven care staff are NVQ, level 2 or 3, trained in care whilst a further three care staff are currently Ashleigh House Care Home DS0000002188.V376620.R01.S.doc Version 5.2 Page 21 completing the NVQ level 2 or 3, in care training. The Registered Manager of the home and a Senior Carer are also NVQ Assessors. We observed a sample of staff recruitment files and it was evidenced that these files did not contain all items required under the Care Homes Regulations 2001 (as amended); there were no recent photographs or proof of identity observed. We observed that the home has an Equal Opportunities policy in place and is an equal opportunities employer. We observed the staff training matrix and individual staff training files which, confirmed that Infection Control, Health and Safety, Food Hygiene, Fire Safety and Moving and Handling training has been conducted within the last twelve months. The Registered Manager reported that further training in Deprivation of Liberties, Safeguarding Vulnerable Adults and the Mental Capacity Act will be conducted in the coming months. From the records viewed we observed that additional training is also provided in other subjects that arise from changes in individuals needs. The Registered Manager confirmed that six staff administer medications, though records viewed provided evidence that four staff had received recent updates. The two staff who had not received an up date, were recorded as last having had medication training in 2004. Ashleigh House Care Home DS0000002188.V376620.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service experience the benefits of a home that is well managed and administrated. EVIDENCE: The Registered Manager of the home has worked in a care environment, working with older people for twenty years and has achieved the NVQ level 4 in Management, is Train the Trainer qualified in The Mental Capacity Act and Safeguarding Adults and is an NVQ Assessor. Ashleigh House Care Home DS0000002188.V376620.R01.S.doc Version 5.2 Page 23 Survey responses and people who use the service that were spoken with said that the Registered Manager is friendly, approachable and always takes concerns or comments seriously. Comments received in surveys include: ‘I feel that the staff can talk and share ideas very easily whenever there is a problem. The team work very well together’ and ‘I love my boss, I think she is amazing – all staff are very well trained’ From records viewed and discussions with the Registered Manager we observed that a formal quality monitoring system is in place. The Registered Manager reported that having now been in post for a year, annual questionnaires will be conducted. The Registered Manager reported that the home does not take any responsibility for many of the individual’s finances and most people have family, friends or representatives who protect their financial affairs. Personal Allowance accounts are maintained for many of the people who use the service, detailed accounts of which are maintained. From the accounts and procedures observed, we evidenced that two staff sign for all transactions, accounts are periodically audited, all monies are kept locked in a safe place and all monies are maintained in individual money bags. The home’s AQAA, observations made on the tour of the premises and records viewed provided evidence that fire drills, fire alarm testing and fire equipment checks, health and safety checks and water checks had been carried out. From the tour of the premise we observed that all food products were stored in the appropriate container, fridge or freezer. Ashleigh House Care Home DS0000002188.V376620.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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 2 X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Ashleigh House Care Home DS0000002188.V376620.R01.S.doc Version 5.2 Page 25 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 OP9 Regulation 13 Requirement That medication fridge temperatures are recorded on a daily basis to ensure that medication efficacy is maintained by being stored in an appropriate manner. This is an Immediate Requirement. 2. OP21 23 That the shower room on the ground floor is redecorated and made fit for purpose. That you seek advice from an appropriate authority with regards to safe and hygienic sluicing practices in the absence of a sluicing washing machine, in order that the risk of cross contamination is reduced. This is an Immediate Requirement. 4. OP26 23 That an appropriate washing machine with a sluicing facility is installed, in order that the risk of cross contamination is reduced. DS0000002188.V376620.R01.S.doc Timescale for action 04/08/09 04/01/10 3. OP26 23 06/08/09 04/10/09 Ashleigh House Care Home Version 5.2 Page 26 5. OP29 19 That staff files include all items specified by this regulation and the associated schedules, in order to ensure that the people who use the service are further safeguarded by the homes recruitment procedures. That all staff who administer medication receive up to date training in medication procedures, in order to further reduce the risk of harm associated with potential medication errors. 04/10/09 6. OP30 18 04/11/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP3 OP7 Good Practice Recommendations That the pre admission assessment is updated to include information of where the assessment took place. That all pages of the care plan are named for the DS0000002188.V376620.R01.S.doc Version 5.2 Page 27 Ashleigh House Care Home individual that they relate to. 3. OP19 The refurbishment programme should continue to ensure that people live in a comfortable and homely environment. Ashleigh House Care Home DS0000002188.V376620.R01.S.doc Version 5.2 Page 28 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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