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Inspection on 07/12/06 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 7th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 provides a domestic and comfortable environment. Residents feel respected and enabled to socialise in a manner that is comfortable for them. Residents feel that a good standard of care is provided by the home.

What has improved since the last inspection?

The new acting manager and deputy manager have spent considerable time and effort to address the issues raised at previous inspections. The new management team and staff are committed to improving standards of care and activities of daily living for the residents. The care plans for residents have been developed and now include details of what actions staff need to undertake to support residents with personal, health and social needs.There are now risk assessments to highlight risks to individuals and around the home. These are detailed with action plans for staff so they are clear as to what to do to avoid injury to residents and themselves. The acting manager has improved the management of medication within the home. There was evidence that staff are now receiving some training in Health and Safety subjects, which will further promote the health and welfare of residents. The recruitment process for staff has also improved. The process for evaluating and checking staff suitability is now in place and more suitable records are being maintained to help protect residents. Improvements to resident`s care have been positively identified and are detailed within this report. Improvements have been made to parts of the home`s internal decor. Some areas have been re-decorated, bathrooms have been refurbished and all are now in working order with suitable aids and adaptations.

CARE HOMES FOR OLDER PEOPLE Ashleigh House Care Home 18-20 Devon Drive Sherwood Nottingham NG5 2EN Lead Inspector Andrew Sales Key Unannounced Inspection 7th December 2006 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.V323204.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.V323204.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 acting manager (if applicable) Type of registration No. of places registered (if applicable) 0115 969 1165 Mr William Scott N/A 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.V323204.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th October 2006 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. Ashleigh House Care Home DS0000002188.V323204.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was conducted by A.J.Sales on 7 December 2007 at 10.00am. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for residents and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. The primary method of inspection used was ‘case tracking’ which involved selecting residents and tracking the care they receive through review of their records, discussion with them, the care staff and observation of care practices. Discussions were also held with the new acting manager and records, documents and policies were inspected. All of the key standards were inspected on this occasion. Due to the number of outstanding requirements set at previous inspections, the inspector focused on obtaining evidence as to whether these have or are being addressed. What the service does well: What has improved since the last inspection? The new acting manager and deputy manager have spent considerable time and effort to address the issues raised at previous inspections. The new management team and staff are committed to improving standards of care and activities of daily living for the residents. The care plans for residents have been developed and now include details of what actions staff need to undertake to support residents with personal, health and social needs. Ashleigh House Care Home DS0000002188.V323204.R01.S.doc Version 5.2 Page 6 There are now risk assessments to highlight risks to individuals and around the home. These are detailed with action plans for staff so they are clear as to what to do to avoid injury to residents and themselves. The acting manager has improved the management of medication within the home. There was evidence that staff are now receiving some training in Health and Safety subjects, which will further promote the health and welfare of residents. The recruitment process for staff has also improved. The process for evaluating and checking staff suitability is now in place and more suitable records are being maintained to help protect residents. Improvements to resident’s care have been positively identified and are detailed within this report. Improvements have been made to parts of the home’s internal decor. Some areas have been re-decorated, bathrooms have been refurbished and all are now in working order with suitable aids and adaptations. What they could do better: The homes general policies are largely outdated and require reviewing to bring them in line with current legislation and good practise. The medication policy needs to be further developed to address issues raised in the pharmacy audit. A number of issues detailed in this report need to be addressed to further promote the Health and Welfare of residents at Ashleigh House. These are highlighted throughout the report and listed as requirements in the table at the end of the report. The acting manager must ensure that remaining staff receive training appropriate to their work. Improvements to the fabric of the kitchen have been identified and need attention. The framework for the social and recreational stimulation of the residents needs to be further developed and improved. Please contact the provider for advice of actions taken in response to this Ashleigh House Care Home DS0000002188.V323204.R01.S.doc Version 5.2 Page 7 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.V323204.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.V323204.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): 3,4,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Significant progress has been made to improve the admission procedure to ensure that residents receive a proper assessment prior to moving into the home. EVIDENCE: The records of three resident’s were checked as part of this inspection. The files contained new assessments conducted by the acting manager. Where appropriate local authority extended social care assessments were present. All of the assessments contained satisfactory information to enable staff to understand the residents assessed needs. Staff spoken with confirmed that these improved assessments identified more accurately the care needs of the residents. Ashleigh House Care Home DS0000002188.V323204.R01.S.doc Version 5.2 Page 10 All of the residents spoken with said they felt staff were competent and polite and were aware of their needs. The resident’s, one of which was a new to the service, said that they were consulted over their care needs and had the service explained to them, prior to moving in to the home. The service does not provide intermediate care. Ashleigh House Care Home DS0000002188.V323204.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 good. This judgement has been made using available evidence including a visit to this service. Significant progress has been made on improving arrangements to ensure that the health care needs of residents are identified and met. Residents feel they are treated with respect by the staff at the home. EVIDENCE: The three residents whose records were checked as part of this inspection had satisfactory assessment plans in place. The records now show that the plans are being reviewed about once each month and that resident’s and where appropriate their representatives, are being involved in the review process. Ashleigh House Care Home DS0000002188.V323204.R01.S.doc Version 5.2 Page 12 The inspector observed risk assessments, which are now documented in each of the resident’s plans. Particular attention is placed on the need to prevent pressure sores, falls and safe working practices. Evidence gained from speaking to residents and staff suggested the care planning process was accurate and outcomes satisfactory. Resident’s plans contain details of each person’s health care needs, including tissue viability and continence risk assessments. There is evidence that people have been appropriately referred to health care professionals. Care plans viewed, contained records of visits by district nurses, General Practitioners and other professionals. Staff training records evidenced that medication training is now provided for staff responsible for the administration of medication. The homes medication administration systems have been improved. The acting manager demonstrated how the Boots pharmacy now provide medicines for the home’s residents and provide training for staff and audit the homes procedures for managing medicines. The recent pharmacy audit states the home is required to review its policy on medication. Medication records were observed as satisfactory and evidence of medication reviews and updates were found on care plans. The inspector observed how evidence of social and recreational stimulation is recorded in care plans. The care plans did not confirm how these needs were to be met. The care plans also now focus on how resident’s privacy and respect is to be promoted. The acting manager described how one resident, who had been confined to bed for some years, is now able to be transferred to a chair for periods of the day. The inspector was introduced to this individual and assessed the individual’s care plan. This provided positive evidence of how the culture of the home is changing to improve people’s everyday lives. All residents spoken with maintained that the staff were courteous and respectful of their wishes and choices. Staff spoken with, demonstrated a clear appreciation of the need to ensure resident’s privacy and dignity are promoted and knowledge of the ways this can be achieved. Staff were observed interacting with residents with patience and sensitivity. Ashleigh House Care Home DS0000002188.V323204.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): 12,13,14,15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The daily routine is flexible to meet the preferences of residents and they are encouraged to exercise choice. Residents are generally happy with the food and choices provided. Attention needs to be focused on meeting the social and recreational needs of all residents. EVIDENCE: A number of residents were observed coming and going to and from the home. Records showed that some residents regularly go out. Some of the residents spoken with felt they were happy with the level of activities within the home and outside. Other residents said they could not always get out when they wanted to. Whilst social preferences are recorded on care plans there is no specific structure to assess residents wishes and allocate resources to meet these needs. It is recognised by the commission that this problem has been evident Ashleigh House Care Home DS0000002188.V323204.R01.S.doc Version 5.2 Page 14 for some years and has been neglected due to the absence of a long term acting manager. The new acting manager acknowledged that more time and resources are required to promote social and recreational facilities for people and demonstrated a commitment to resolving this. He also described that he had recently organised shopping trips and outings for some residents prior to the Christmas holidays. The acting manager also demonstrated how personal choices were now being balanced with the risks involved to enable residents to make more choices as to how and what they would like to do. One resident described how his condition of epilepsy is managed through medication and what support measures have been put in place by the home to ensure he can still go out. All residents spoken with said they were pleased with the flexible routines within the home and that it was a relaxing place to be. Staff described flexibility over the daily routine and all four of the residents spoken with said that they are able to decide when they want to do things. A number of people living in the home were spoken with and everyone who commented on the food said how they looked forward to meal times and that they welcomed the daily choices offered. Menus were found to be fairly well balanced and meal times are flexible to suit the needs of individuals and the resident group. Ashleigh House Care Home DS0000002188.V323204.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaints are now handled properly to provide residents with confidence that their concerns will be listened to, taken seriously and acted upon. The vulnerable adults procedures have improved to help make sure that the people living in the home are protected from abuse. Though as not all of the staff are trained in the Protection Of Vulnerable Adults, this could potentially put residents at risk. EVIDENCE: The inspector observed a complaints procedure and how the acting manager records complaints and outcomes. Complaints records were assessed on this occasion and found to be satisfactory. The resident’s who the inspector spoke with, stated they had not had occasion to make any complaints but would approach the acting manager or staff with issues if they felt it necessary. The Nottinghamshire Policy for the Protection Of Vulnerable Adults was observed, together with the homes polices on adult protection. Evidence was obtained from staff files and from acting manager and staff comments, which confirms that training in Adult Protection is now in progress. Ashleigh House Care Home DS0000002188.V323204.R01.S.doc Version 5.2 Page 16 Some certificates were observed and it is the registered providers responsibility to ensure all staff who now work at the home have received this form of training. The staff spoken with demonstrated a good understanding of their roles and responsibilities in the protection of vulnerable adults. There have been no complaints received by the commission since the last inspection. Ashleigh House Care Home DS0000002188.V323204.R01.S.doc Version 5.2 Page 17 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): 19,21,25,26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some improvements to the décor of the building and aids and adaptations have been made which have helped provide safer and more comfortable surroundings in which to live. Some areas have been identified which may put some residents at risk. EVIDENCE: The acting manager showed the inspector around the home. The dining room had been re-furbished prior to the previous inspection. Generally the home is kept clean and reasonably well maintained. Residents said they felt it was homely and they felt comfortable with the surroundings. Ashleigh House Care Home DS0000002188.V323204.R01.S.doc Version 5.2 Page 18 However there are still areas that require attention. The acting manager stated he is planning to put these right. The bathrooms are all now in working order, having been partially redecorated and two have appropriate aids and adaptations. The Environmental Health Department conducted an inspection recently and identified issues that present risk to residents. The hot water outlets are not suitably controlled and measures to control legionella bacteria are not yet in place. The gardens are still largely inaccessible to residents and used to store unsightly rubbish or materials. The kitchen was observed to have the following areas of concern. Window frames have nails protruding internally to act as fixings for window closure. Window frames need painting, one window frame bowed to ½ inch externally. There was no mesh screening present for the windows. There are cracked corner tiles near kitchen window and missing tiles near wash hand basin leaving this area prone to bacteria. This also brings into question the effectiveness of cleaning schedules in this area. Ashleigh House Care Home DS0000002188.V323204.R01.S.doc Version 5.2 Page 19 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. The procedures for the recruitment and training of staff are more robust and now offer increased protection to people living in the home, however….induction ….etc. The deployment and number of staff available in the early morning has improved to meet the needs of the residents. EVIDENCE: The recruitment process has improved considerably. Evidence was provided by the acting manager, staff comments and from files, that satisfactory interviews and pre-employment checks are being carried. This will help ensure the right staff are employed at the home. Satisfactory police checks were observed for those persons on duty. On the day of the inspection there were sufficient numbers of care, domestic and kitchen staff on duty. Rotas were observed and staff and residents felt there is more continuity and stability within the staff group. Comments were received from four residents, who felt there were adequate care workers and senior staff available on duty and that they did not have to wait long for assistance. Ashleigh House Care Home DS0000002188.V323204.R01.S.doc Version 5.2 Page 20 Staff were observed supporting residents with patience and the atmosphere felt unhurried. Those residents that were identified with higher support needs were introduced to the inspector. They had specific plans of care with key times for certain tasks. There was evidence of these tasks being satisfactorily carried out and recorded in care records. This was also supported by comments from one of these residents. Evidence was provided as to how one resident who previously had been confined to bed, was now able to get up twice a day, with extra staff support and the use of suitable aids and adaptations. Both staff members spoken with, demonstrated an understanding of their roles and responsibilities and a some insight into the methods of promoting independence whilst supporting older people. There is now evidence, provided by staff comments, staff files and the acting manager’s comments, to suggest that some training is now taking place. Some staff have been trained in the basic health and safety subjects or subjects relating to the care of older people, but not all staff have all the required health and safety training and this could still put the residents at risk. A file of a new member of staff contained evidence of an appropriate induction programme being carried out. A suitable induction training and development programme needs to be further developed to ensure current and new staff have the right skills to support the resident in the home. The acting manager demonstrated plans to address this. It is evident that the acting manager has a considerable backlog of work to address training and development issues, and it is acknowledged what progress has been made so far. The National Vocational Qualification (NVQ), has not been addressed prior to the new acting managers appointment and he has described intentions to address this, though currently there is no evidence to support this. Ashleigh House Care Home DS0000002188.V323204.R01.S.doc Version 5.2 Page 21 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 poor. This judgement has been made using available evidence including a visit to this service. The home is now being managed more effectively and there is more leadership, guidance and direction to staff to ensure residents receive better quality care. This has improved practices that promote and safeguard the health, safety and welfare of the people using the service. Until the manager has been registered with the commission he has no legal responsibilities and therefore an application to register needs to be made urgently. Ashleigh House Care Home DS0000002188.V323204.R01.S.doc Version 5.2 Page 22 EVIDENCE: Residents said they felt the home has improved because the new management team were committed to making things better. They said the management team were always on hand for support and advice. Residents stated that they felt they were now consulted about day to day issues. Residents meetings are now planned and residents described how they have enjoyed these. Staff spoken with, confirmed that they felt supported by the acting manager and that they are approachable to discuss any issues. The staff confirmed they receive more frequent supervision and have started to attend team meetings. There is verbal and written evidence present, which supports the acting manager’s commitment to providing effective supervision for staff. Evidence was observed on files of staff support and disciplinary issues being discussed and recorded. Evidence of the acting manager’s contribution to the improved running of the home has been demonstrated throughout this inspection. The inspector was unable to assess the acting manager’s recruitment and background on this occasion, but was advised that an application to register with the commission was due to be submitted. A requirement has been set to ensure an application is submitted. Some staff files observed evidenced that staff have now undertaken training in some mandatory health and safety subjects. This is a great improvement since the last inspection, though the whole staff group are required to have received training in all of the mandatory health and safety subjects, including the protection of vulnerable adults. The provider must ensure adequate resources are made available to the acting manager to effectively plan this. Staff spoken with, were generally aware of health and safety procedures and commented that some training was now being provided. The inspector observed a satisfactory policy with regards to the safe keeping of resident’s personal allowances. The resident’s accounts were observed and one was randomly sampled and checked as part of this inspection. The inspector observed some health and safety monitoring activity, which is regularly carried out. This includes regular checks of fire alarms and emergency lighting tests. Tests for legionella bacteria in the homes water supply, were conducted by a contractor on 27/11/06. This inspection identified control measures that need Ashleigh House Care Home DS0000002188.V323204.R01.S.doc Version 5.2 Page 23 to be introduced by home. These include six improvement notices, which include measures to control hot water temperatures at outlets and controls to be put in place for the control of legionella bacteria. These are required to ensure the safety of the residents at the home who may be at risk of scalding and infection. The acting manager has introduced a number of ways to assess risks to residents and staff throughout the home. The inspector observed environmental risk assessments and individual risk assessments for each resident with action plans to ensure that staff are aware of these and know how to prevent accidents. The general policies and procedures at the home are considerably out of date and must be reviewed to reflect current legislation and good practice. To ensure the safety of residents the acting manager needs to ensure that the following issues are addressed: • • • • • A Fire Risk Assessment needs to be conducted for the home. The issues raised by the pharmacist require attention. The issues raised by the Environmental Health Department require attention. Electrical and gas installations must be checked at the required frequency. The Health and Safety issues identified in the kitchen. Ashleigh House Care Home DS0000002188.V323204.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 3 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X 3 X X X 1 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 2 Ashleigh House Care Home DS0000002188.V323204.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 OP9 Regulation 13.2 Timescale for action The registered person shall make 09/02/07 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. Ensure the requirements of the Pharmacy audit are addressed. 2 OP12 16.2.m The registered person shall having regard to the size of the care home and the number and needs of service users consult service users about their social interests, and make arrangements to enable them to engage in local, social and community activities and to visit, or maintain contact or communicate with, their families and friends. 09/03/07 Requirement 2 OP18 12(1,a)13 (6) Ensure the social needs of residents are planned for and met. The registered person shall make 09/02/07 arrangements, by training staff or by other measures, to prevent service users being harmed or DS0000002188.V323204.R01.S.doc Version 5.2 Page 26 Ashleigh House Care Home suffering abuse or being placed at risk of harm or abuse. Ensure all remaining staff receive training in adult protection. The registered person shall 09/04/07 ensure that external grounds are suitable for, and safe for use by, service users are provided and appropriately maintained; The registered person shall make 09/02/07 suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home and all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety; Ensure the issues addressed in the Environmental Health Department report are addressed urgently. The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users, ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. The Ensure all staff are registered to undertake the National Vocational Qualification program. Ensure a staff training and development program is developed that meets National Training organisation standards. The Registered person shall ensure that the persons DS0000002188.V323204.R01.S.doc 3.. OP19 23.2.o 4. OP25 OP38 16. 13(3)(4)( a)(c) 5 OP28 18 01/08/07 6 OP30 19.5.a 18.1.a.c 18.1.c.i. 01/08/07 7. OP30 OP38 01/06/07 Ashleigh House Care Home Version 5.2 Page 27 employed by the registered person to work at the care home receive training appropriate to the work they are to perform; Ensure all the remaining staff receive Health and Safety training updates each year. Ensure the manager is registered 28/02/07 with the Commission. The registered person shall after consultation with the fire authority, ensure a Fire Risk Assessment is developed for the home. The registered person shall ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety; any activities in which service users participate are so far as reasonably practicable free from avoidable risks Ensure electrical and gas installations are serviced at the required frequency. The registered person shall ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of service users and to make proper provision for the care and, where appropriate, treatment, education and supervision of service users. Ensure the homes policies and procedures are reviewed to reflect current legislation and practice. 01/03/07 8 9 OP31 OP38 8 23.4 10 OP38 13.4 01/03/07 11 OP38 12. 13 01/08/07 12 OP26 16.2.j. The registered person shall DS0000002188.V323204.R01.S.doc 01/04/07 Version 5.2 Page 28 Ashleigh House Care Home OP38 ensure after consultation with the environmental health authority, make suitable arrangements for maintaining satisfactory standards of hygiene in the care home. Ensure that the items identified in the kitchen area are repaired and maintained. 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 OP19 Good Practice Recommendations Ensure the office is suitably equipped for the purpose of running the home. Ashleigh House Care Home DS0000002188.V323204.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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.V323204.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!