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Inspection on 05/09/07 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 5th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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 will contact healthcare professionals to see to the healthcare needs of residents and their health is monitored through observation and regular health checks. Medication is given out following the recommended safe procedures to make sure that residents are not put at risk when being given their medication. Care is provided in a way that promotes the privacy and dignity of residents. There is a varied menu providing a choice at each meal so that residents have a nutritious and balanced diet.

What has improved since the last inspection?

The requirements set at the last visit have not been complied with.

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE Ashleigh House Care Home 18-20 Devon Drive Sherwood Nottingham NG5 2EN Lead Inspector Stephen Benson Unannounced Inspection 5th September 2007 10:00 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.V342249.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.V342249.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 Graham Moulds 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.V342249.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th April 2007 Brief Description of the Service: Ashleigh House is a care home providing personal care and accommodation for 19 older people. The home provides short and long term care. 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. The home was opened in 1987 and consists of 2 converted terraced houses with a purpose built extension. Fifteen of the homes bedrooms are single, and 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 home has recently appointed a new acting manager. The fees for the service are listed in the Service User guide as £275 - £305 £326 per week depending on dependency needs. There are additional charges for hairdressing and chiropody. Further information about the home is available from the provider or acting manager. A copy of the latest inspection report is available in the office. Ashleigh House Care Home DS0000002188.V342249.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second visit to the home since 1st April 2007 by The Commission for Social Care Inspection. Prior to the visit an analysis of the home was undertaken from information gathered over the last year. The visit centred on looking at the key National Minimum Standards for older people. The site visit lasted for 4 hours and the main method of inspection used was called case tracking which involved selecting 3 residents and tracking the care they receive through the checking of their records and discussing this with them. Other residents were spoken with and additional records were seen. A discussion was had with the provider, staff on duty and care practices were observed. The acting manager was not on duty and no visitors came to the home during the visit. The premises were not inspected in detail but various areas of the home were visited as part of the inspection. The Annual Quality Assurance Assessment, which all care homes are required to complete, had not been returned and the provider said he did not know about this. Survey forms were not sent out to the home on this occasion. The registration certificate was checked and found to be incorrect and a replacement one has been requested. What the service does well: What has improved since the last inspection? Ashleigh House Care Home DS0000002188.V342249.R01.S.doc Version 5.2 Page 6 The requirements set at the last visit have not been complied with. What they could do better: 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.V342249.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Ashleigh House Care Home DS0000002188.V342249.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. New residents are not properly assessed prior to moving into the home to ensure that their needs can be met and they are not provided with information about the home. The home does not offer an intermediate care service. EVIDENCE: There has not been a new admission to the home since December 2006. The file of the last resident to be admitted was looked at and this included a Community Care Assessment, however this was incomplete and had assessed the resident’s options as receiving day care. There was not any explanation as to why the resident was then admitted into residential care and there was not an assessment completed by the home prior to the resident moving in. A senior care staff said that she thought the acting manager would go out to Ashleigh House Care Home DS0000002188.V342249.R01.S.doc Version 5.2 Page 9 assess any new resident before they moved to the home. Staff spoken with said they did not know what would happen with a new admission, as there had not been one since they had started work at the home. A resident said, “I can’t remember if anyone came to see me”. There is no arrangement made for the home to provide an intermediate care service. Ashleigh House Care Home DS0000002188.V342249.R01.S.doc Version 5.2 Page 10 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 and 10 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans do not reflect the needs of residents although their healthcare needs are being met and residents are treated with respect. EVIDENCE: A sample of three care files were looked at and the plans in these were written clearly, however they did not address all the needs of the residents. For example, one care file had care plans for shaving and foot care, mobility, getting ready for bed and social stimulation. These had not been updated since April 2007 and the resident had deteriorated considerably since then. Entries in the daily communication sheets referred to severe continence problems, wandering, becoming unsteady and appearing confused. There was no mention of these difficulties in the care plans. Ashleigh House Care Home DS0000002188.V342249.R01.S.doc Version 5.2 Page 11 One care plan seen referred to a resident having Munchausen’s syndrome. There was no evidence to support this diagnosis. This was raised at a previous inspection. There was no sign of residents being involved in the preparation or review of their care plans and there were not any details of residents’ ethnic origin. A senior carer said that care plans are in a bit of a mess at the moment as there have been several managers at the home over a short space of time and they system keeps getting changed but not completed. Staff said they make records in the daily communication sheets, but are plans are not kept up to date. When asked if she had discussed her care plan with anyone a resident said, “What is that?” There were entries in the daily communication sheets referring to residents being seen by healthcare professionals, including doctors, district nurses, opticians and chiropodists. One member of staff was heard making an appointment for a resident’s hearing aid to be repaired. The member of staff said it had been working when she was last on duty so had not been broken for long. A senior carer said a doctor is called if something is wrong and that opticians, dentists and chiropodists all visit the home. A resident said, “I keep very well, staff ask me how I am feeling”. The morning medication round was observed and this was done following the recommended safe practices, including locking the drugs trolley when leaving it and watching residents take their medication. There are currently not any residents who are self medicating. A senior care said staff have to complete the safe handling of medicines course before they are able to give out medication and this is normally done by one of the senior carers or the acting manager. A member of staff said safe practices are always followed when administering medication. A resident said, “Staff bring me my tablets every morning and I ask for painkillers if I have a headache”. Staff were seen talking with residents in a respectful manner and crouching Ashleigh House Care Home DS0000002188.V342249.R01.S.doc Version 5.2 Page 12 down to the same level when talking to residents who were sat down. They were seen laughing and joking with residents. Staff were aware of good practices to promote residents’ privacy and dignity through providing care in private with doors closed and protecting their modesty, knocking on doors and explaining to residents what they are going to do when assisting them. A resident said “staff always knock on my door”. One resident was currently in hospital and his bedroom door had not been locked. Ashleigh House Care Home DS0000002188.V342249.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is little stimulation for residents who are left to their own devices a lot of the time and the majority rarely leave the home. Residents are provided with a varied diet which they enjoy. EVIDENCE: There is a sheet to record any activities residents take part in in their care file. The only entries for residents’ case tracked were watching television, been to shops and visitors. The senior care said that these residents don’t take part in activities, but when asked to show records for residents that do the only other entries were a sing-along on 22/07/07 and playing dominoes on 30/08/07 and 02/09/07. One senior care staff said that there could be more frequent things to do and another said there is not enough but would not be sure how many would bother. Ashleigh House Care Home DS0000002188.V342249.R01.S.doc Version 5.2 Page 14 Staff said that residents get the care they need but not the activity, and that we have a laugh and a joke but that is not everything, they just go back to sleep again. Staff said that the occasional singer comes in and some residents enjoy playing dominoes. A resident said, “I like reading, there’s nothing organised as far as I know”. One resident was seen returning at lunchtime having been out for the morning, staff said that is his daily routine and that there is another resident who goes out unescorted. Staff said that they take residents to the shops now and then, but they don’t get out very often. Records showed that visitors regularly come to the home and staff said they are always welcome. Staff were heard discussing that one resident was having a lie in and residents were seen coming down for breakfast at different times. A senior care described different routines of some residents, for example one likes to go out every morning and another likes to knit after breakfast and that residents are free to move around the home freely. Staff said that residents choose when they want to do things such as get up and go to bed. A resident said, “I press the buzzer and ask to get up or go to bed. One night staff came at 6.30 pm, but I wasn’t ready and told them to come back at 7.00 pm”. The food stocks appeared to be low, however staff said that a food delivery is due and showed a handwritten order. There is a 4 week menu and the main meal is at lunchtime and dishes include pork stew, spam fritters and liver and onions. There is a different type of fish on Fridays and a roast dinner on Sundays. There is always a choice provided. A lighter meal is had at teatime with such things as kippers, scrambled egg, salads and sandwiches. A pudding is provided at lunch and cakes at teatime. Residents were seen having cereals and toast for breakfast. One resident was seen given a piece of burnt cold toast. Another member of staff took this back to the kitchen and asked for it to be replaced. Lunch was a choice of gammon or fish fingers, chips or mashed potato, peas or beans. Residents were asked what they wanted and were given what they requested. There was plenty to eat and residents were offered seconds if they Ashleigh House Care Home DS0000002188.V342249.R01.S.doc Version 5.2 Page 15 wanted. Six residents were asked if they enjoyed their lunch and they all said that they had. Ashleigh House Care Home DS0000002188.V342249.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Measures are not in place to protect residents from abuse. EVIDENCE: A copy of the complaints procedure was available in the entrance hall in the service user guide. Despite a lengthy search staff or the provider were unable to find a complaints book. A senior care said there had not been any complaints made. A resident said, “I know what to do if I want to complain, I go to the manageress. Two staff were taking the micky out of me, which I didn’t like. I warned them first but they carried on so I told the manageress. They treat me properly now. A senior care said that she did not know where the adult protection procedures were. Staff also said they did not know and had not seen the whistleblowing policy. A matrix of staff training showed that there were five staff who have not had training in safeguarding adults. Ashleigh House Care Home DS0000002188.V342249.R01.S.doc Version 5.2 Page 17 A resident said, “I feel quite safe here”. Ashleigh House Care Home DS0000002188.V342249.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The physical standards of the home could be gratefully improved although it is kept clean. EVIDENCE: There were areas of the home that were in need of decorating. This varied from torn wallpaper, unpainted plaster and general wear and tear. There was a large piece of plasterboard cut out to make an entrance to an area of pipe, which was still hanging directly above the toilet. This was pointed out to the provider who agreed this presented a hazard and pulled it off. This will now need to be repaired. Ashleigh House Care Home DS0000002188.V342249.R01.S.doc Version 5.2 Page 19 There was not an emergency cord pull within reach of this toilet. The home has a garden but this has not been made suitable for residents use and there are patches of building rubble lying around. The gardens are difficult for residents to access. There was an electric hedge cutter seen in a corridor. This was pointed out to the provider who agreed this presented a risk to residents’ safety and moved it. A senior care said that the garden isn’t suitable for residents to use and that some parts of the home are nice and others need painting and touching up. Staff said a lot of building rubble has been removed from the garden, but should be better and more could be cleared. A resident said, “I am happy with the home, I like having my own room”. There was a cleaner on duty and was cleaning various areas of the home. The lounge was cleaned whilst residents had lunch. Staff were seen wearing protective aprons and gloves. Staff said that the building is kept clean, which was also said by a resident. Ashleigh House Care Home DS0000002188.V342249.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing levels are not varied according to the needs of the residents, placing them at risk. Staff have not received all the training they require to carry out their duties. EVIDENCE: There was 1 senior care and 1 care assistant on duty. The cook was on leave and a care assistant was covering the cooking. There was also a domestic on duty. The acting manager was also on leave for the day. A senior care said that she did not think there were sufficient staff on duty that morning, but could not contact anyone, as there was no one available. The provider was contacted and he arranged for additional staff to come on duty as well as coming to the home himself. A senior care said they thought that there was a need for 3 care staff to be on duty during the day, which was a view shared by staff. Some said they thought the current night time arrangements of one person awake and 1 Ashleigh House Care Home DS0000002188.V342249.R01.S.doc Version 5.2 Page 21 sleeping in are suitable but others said they did not feel they could keep residents safe and one resident wanders at night time. There was an incident recorded where a resident was found twice having been incontinent one night, once on the lower ground floor and another having been in another resident’s room. This resident is not currently at the home, but the staffing levels were not adjusted when he was. A resident said, “I think they are short of staff at the moment which has made it a bit difficult”. A selection of staff files were seen and these contained some training certificates and there was a training matrix on the office wall. Staff said there are 4 staff who have completed National Vocational Qualification level 2 and 2 staff showed their certificates for this. Staff files contained an application form, 2 references and a Criminal Records Bureau check. A recently started member of staff said the provider had interviewed her and she had not started work until her Criminal Records Bureau check had been returned. There were a number of gaps shown on the training matrix. Recent training provided has been 1st Aid on 02/03/07 and Basic Food Hygiene on 22/03/07. Staff also said they had been trained to use a peg feed. A resident said, “They seem to be properly trained, they are very careful when getting me out of bed. Ashleigh House Care Home DS0000002188.V342249.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 and 38 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are being placed at risk due to the frequent changes of manager in the home, resulting in staff being unclear as to what is expected of them and residents are placed at further risks due to routine safety checks not being carried out. EVIDENCE: There have been several changes in manager at the home and this as given as the reason by staff for the problems that exist in the home. Ashleigh House Care Home DS0000002188.V342249.R01.S.doc Version 5.2 Page 23 The current acting manager has not submitted an application to be registered, but the provider said that she was waiting for the return of her Criminal Records Bureau check. The provider said he visits the home regularly, sometimes three times a day, but he does not record any of these visits as required. The provider said he did not know anything about a quality assurance review of the home’s services and he also did not know about then Annual Quality Assurance assessment he is required to complete. Staff also said they did not know about these. The fire log showed that fire safety tests are not being carried out at the required frequency and the last test was 14/08/07. The water testing required for the prevention of Legionella is not being done at all. The provider could not find the Environmental Health report to establish if the outstanding requirements have been complied with and was unable to show a fire risk assessment for the home. Ashleigh House Care Home DS0000002188.V342249.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 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 1 X X X X X X 3 STAFFING Standard No Score 27 1 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X X X X 1 Ashleigh House Care Home DS0000002188.V342249.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14(1)(a) Requirement All prospective residents must be assessed prior to moving to the home to establish whether their needs can be met within the home. Care plans must clearly describe how resident needs are to be met and kept updated when there is any change. This will ensure that staff know how to meet residents’ needs. This is a repeated requirement the previous timescale of 11/04/07 was not complied with. Details of residents’ ethnic origin must be included in the care plan. This will ensure that any resulting needs are identified. More frequent and varied activities must be provided. This will ensure that residents have opportunities to spend time doing things they find enjoyable and stimulating. This is a repeated requirement the previous timescale of 11/04/07 was not complied with. Ashleigh House Care Home DS0000002188.V342249.R01.S.doc Version 5.2 Page 26 Timescale for action 01/01/08 2. OP7 15(1) 01/02/08 3. OP7 15 (1) 01/02/08 4. OP12 16(2)(n) 01/01/08 5. OP16 17 (2) The complaints book must be available at all times so that anyone can make a complaint if they wish. 01/01/08 6. OP18 12 (1)(a) This is a repeated requirement the previous timescale of 30/05/07 was not complied with. All staff must be familiar with the 01/01/08 procedures to follow to safeguard residents if there is any suspicion of abuse. This will ensure that staff know how to protect residents. This is a repeated requirement the previous timescale of 11/04/07 was not complied with. The home must be kept in a good state of decor The grounds must be suitable and safe for use by residents. 7. 8. OP19 OP19 23(2)(b) 23(2)(0) 01/02/08 01/04/08 9 OP27 18 (1)(a) 10 OP30 18(1)(c) (i) This is a repeated requirement the previous timescale of 11/04/07 was not complied with. There must be sufficient staff on 01/01/08 duty at all times. This will ensure that staff are available to meet residents needs. Ensure all staff have received the 01/03/08 training they require to carry out their duties This is a repeated requirement the previous timescale of 11/04/07 was not complied with. There must be a registered manager in post This is a repeated requirement the previous timescale of 11/04/07 was not complied with. Ensure provider appropriate monitoring visits are conducted and recorded at the required frequency. DS0000002188.V342249.R01.S.doc 11 OP31 8 01/03/08 12 OP33 26 01/01/08 Ashleigh House Care Home Version 5.2 Page 27 13. OP33 24 (1)(a) This is a repeated requirement the previous timescale of 30/04/07 was not complied with. A quality assurance system must be used. This will ensure that residents are able to put forwards their views on the running of the home. This is a repeated requirement the previous timescale of 30/06/07 was not complied with. The required health and safety checks must be carried out at the required frequency to prevent residents being exposed to danger Obtain a copy of the Environment Health report and ensure the requirements within are complied with. This is a repeated requirement the previous timescale of 11/04/07 was not complied with. Ensure a fire risk assessment is developed for the home. This is a repeated requirement the previous timescale of 11/04/07 was not complied with. 01/03/08 14. OP38 12(1)(a) 01/01/08 15. OP38 12(1)(a) 01/02/08 16. OP38 23(4)(a) 01/02/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ashleigh House Care Home DS0000002188.V342249.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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.V342249.R01.S.doc Version 5.2 Page 29 - 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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