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Inspection on 12/09/06 for Ashleigh House Nursing Home

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

This inspection was carried out on 12th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 26 statutory requirements (actions the home must comply with) as a result of this inspection.

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 evidence and judgements made in this report, and reports on CSCI Inspections that have recently preceded this one, give very clear indication that Ashleigh House is struggling to achieve the quality of care service as set out in the Care Home Regulations and National Minimum Standards. It is, therefore, not possible to identify any particular area of care that, currently, would fit comfortably under the above heading. It is hoped that the appointment of a Registered Manager will lead to significant improvements in the quality of care provided.

What has improved since the last inspection?

What the care home could do better:

The Home is lacking markedly in many aspects of general management including, strategic planning (e.g. redecoration/refurbishment and maintenance of the environment) and operational management (e.g. poor maintenance of Resident`s records such as personal care Plans). This provides evidence of an urgent need to recruit and appoint a suitable person to fill the Manager vacancy. Fifteen requirements were outstanding from previous inspections. In addition the pharmacist inspector issued nine requirements relating to NMS 20 medication on the 11th August 2006. Seven new requirements were issued as a result of this inspection. As the vast majority of these requirements have a direct impact on service delivery, health, safety and welfare of service users and have been carried over from a number of previous visits CSCI will continue to monitor compliance and where necessary enforcement action will be considered.

CARE HOME ADULTS 18-65 Ashleigh House Nursing Home Ashleigh House 107 Gorge Road Coseley Wolverhampton West Midlands WV14 9RH Lead Inspector Karen Powell Key Unannounced Inspection 12th September 2006 09:00 Ashleigh House Nursing Home DS0000017177.V311705.R01.S.doc Version 5.2 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 Nursing Home DS0000017177.V311705.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 Adults 18-65. 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 Nursing Home DS0000017177.V311705.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashleigh House Nursing Home Address 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) Ashleigh House 107 Gorge Road Coseley Wolverhampton West Midlands WV14 9RH 01902 880886 01902 887738 Ashleigh Healthcare Limited Care Home 19 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (19) of places Ashleigh House Nursing Home DS0000017177.V311705.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Recovering mentally ill aged 19 years to 60 years The home can accommodate one named service user over the 60 years age limit. 19th July 2006 Date of last inspection Brief Description of the Service: Ashleigh House is a care home providing nursing care and accommodation to 19 adults with enduring mental ill health. It is owned by Ashleigh Healthcare Ltd and is part of a group of care homes providing a variety of care services. The home is located in the Coseley area of Wolverhampton and is on a main bus route into the city. Local shops, pubs and local amenities are close by. The home consists of a two-storey building, which has been converted to provide accommodation of 17 single occupancy bedrooms and one twin room. There is a dining room, two lounges and a designated smoking lounge. Currently the statement of purpose does not meet national minimum standards; therefore detailed information about the service is not readily available to prospective service users and their representatives. The fees per week are 482.00 Ashleigh House Nursing Home DS0000017177.V311705.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 key inspection of 2006/07. Two inspectors carried out the inspection. The visit lasted three and a half hours. It included talking with service users, the manager and members of staff on duty, case tracking service users, observing work practices, looking at a number of records and a tour of the home. 20 key National Minimum Standards for younger adults were assessed in addition to Standards 1 & 26 and a quality rating provided based on each outcome area for service users. These ratings are described as excellent/good/adequate or poor based on findings of the inspection. The service users, acting manager and staff on duty were welcoming and cooperated fully throughout the inspection. No complaints have been received by the home or CSCI since the last inspection. The inspection also focused on following up the progress made with respect to the requirements made at a series of visits to the home as follows; 20th April 2006 1st June 2006 21st June 2006 7th July 2006 (pharmacist inspection) 19th July 2006 11th August 2006 (pharmacist inspection) What the service does well: What has improved since the last inspection? The home has a variety of activities for service users to access, expansion of these is being explored by the acting manager. At the time of this inspection it was noted that no doors were lodged open inappropriately – the Inspector was told that the homes policy is to maintain this practice so that electrical closures linked to the fire alarm system would be unnecessary, a requirement made at the last inspection. Ashleigh House Nursing Home DS0000017177.V311705.R01.S.doc Version 5.2 Page 6 The floor in room 13 has been repaired. There has been improvement in relation to the ambient and refrigerated temperatures at which medicines are stored and also one specific matter relating to safety/environment. Opportunities for staff to undertake training relevant to their roles are being provided. 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. Ashleigh House Nursing Home DS0000017177.V311705.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashleigh House Nursing Home DS0000017177.V311705.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Currently the statement of purpose does not meet national minimum standards; therefore detailed information about the service is not readily available to prospective service users and their representatives. Voluntary suspension of admissions means there have been no new admissions to the service. This standard was therefore not inspected on this occasion. Quality in this area is poor. This judgement has been made using available evidence including a visit to the service. EVIDENCE: A statement of purpose was made available to the inspectors at the visit. A copy of which was taken away to be retained at CSCI. Further inspection of the document revealed that it did not fully meet the national minimum standards and did not contain all the required elements as required under Schedule 1 of the younger adults care home regulations 2001. A service user guide was not made available to inspectors at this inspection, although one was seen at the last key inspection. Ashleigh House Nursing Home DS0000017177.V311705.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 The basic person centred plan model is comprehensive in design, with the potential to satisfactorily enable the delivery of care relevant to service users identified care needs. However, there was evidence of inconsistent application, and of gaps in reporting/record keeping. Quality in this area is adequate. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Three person centred plans were examined at this inspection. There had been no new service users admitted to the home since the last inspection visit therefore the plans were of long term service users. Although the model of care plan in use was appropriate in design content about individuals was lacking in detail in some areas. Ashleigh House Nursing Home DS0000017177.V311705.R01.S.doc Version 5.2 Page 10 Risk assessments for individual service users were not fully covered. Evidence is documented in this report under outcome group conduct and management of the home. Review of service user care plans did not demonstrate evidence of service user consultation, participation or involvement in aspects of their life at the home. This is further addressed in outcome group environment in this report. One service user who spoke to the inspector about their lifestyle at Ashleigh House spoke of their attendance at college and activities they undertake during the week. It was established that these arrangements have been in place for some time. The service user involved told the inspector they enjoyed participating in them. Ashleigh House Nursing Home DS0000017177.V311705.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The effectiveness and continuity of improvements noted at the last key inspection relating to supporting people at the home to establish and maintain their own preferred life styles has not been evidenced at this inspection. Quality in this area is poor. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Discussions with one service user told the inspector that there is a weekly activities board informing service users of what activities are taking place. The acting manager also stated that service users are told on a daily basis what is taking place. It was noted that keep fit is being increased to Mondays in addition to Thursdays. Those service users who wish to spend time improving their cooking skills. Inspectors were informed that the home was proposing to purchase a car to enable small groups of service users to go on trips of interest. It was established at this visit that it has not been possible to pursue holidays for service users, a requirement made at the last inspection. Evidence that the home promotes individuals to make informed choices about lifestyle where applicable was not demonstrated in care plan documentation. Ashleigh House Nursing Home DS0000017177.V311705.R01.S.doc Version 5.2 Page 12 The acting manager told inspectors that the home has designed activity records for service users, when a staff member was asked if these were in use, it was stated that the records were having some further changes made to them. The meal was not observed during the inspection, however one service user told the inspectors they had enjoyed lunch and generally the food was of a good variety and enjoyable. It was established through discussion with service users that contact with families and friends are encouraged by the homes staff team. Although most service users have a key to the front door formal risk assessments have not been undertaken with regard to this activity. A requirement outstanding from previous inspections. Ashleigh House Nursing Home DS0000017177.V311705.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Whilst many aspects of the Homes storage, administration, and disposal of medicines are generally in accordance with accepted good practice there remain a significant proportion where this is not so. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: This area of service provision was partly inspected on this occasion as the Home is in the process of responding to a recent detailed Inspection by the Pharmacist Inspector on 11.8.06 with requirements made at that time being monitored through further focused inspection. For the purposes of this visit the inspection of medicines related services was limited to those set out below. Concerns had previously been raised about the air temperature in the ‘treatment’ room (i.e. found to be in excess of 25o Celsius), and arrangements for the storage of medicines requiring refrigeration (i.e. temperatures recorded which were below 2o Celsius). It was seen at this inspection that these issues had been satisfactorily addressed through the purchase of a mobile airconditioning unit, and adjustments to the refrigerator thermostatic control. However, of particular note (and concern) was that on case tracking one Ashleigh House Nursing Home DS0000017177.V311705.R01.S.doc Version 5.2 Page 14 service user, the MAR sheet recorded a recurrent history of non-compliance in taking some oral medicines. Of particular concern in this instance was that although this had been an ongoing situation for some time the prescribing clinician did not seem to have been involved so as to review the medicines regime for that service user. Ashleigh House Nursing Home DS0000017177.V311705.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 There is a clear complaints procedure in place. Adult protection training is under way to equip the staff with the knowledge and skills needed to recognise potential abuse and the possible effects on service users. Quality in this area is adequate. This judgement has been made using available evidence including a visit to the service. EVIDENCE: A clear complaints procedure is available to service users. It was reported by the acting manager that there had been no complaints made through the homes complaints procedure since the last inspection. There had been none reported to CSCI. The central complaints record was examined as part of the complaints audit. Service users were seen to readily approach the acting manager throughout the inspection with issues important to them. These were not complaints but demonstrated to inspectors the open door policy adopted by the acting manager for service users. The acting manager reported that all care staff has now completed adult protection training. The two newest staff members are due to attend adult protection training on 28th September 2006. The acting manager is attending abuse training for trainers on 15th September 2006. Ashleigh House Nursing Home DS0000017177.V311705.R01.S.doc Version 5.2 Page 16 The financial records of those service users who were case tracked were checked, along with their money kept in safekeeping. Records and balances held were found to be accurate. Ashleigh House Nursing Home DS0000017177.V311705.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 The Home, although generally safe, comprises a worn, shabby, inadequately lit, and poorly maintained environment. This comment applies particularly in the ‘communal areas, although it is true to say that Residents’ bedrooms were also generally dowdy and worn looking. There is an urgent need for the establishment, and application, of a funded programme to upgrade accommodation throughout the Home. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the previous Inspection ‘Requirements’ relating to the following have been met satisfactorily: “. floor in room 13…” The carpet has been lifted, the floor surface levelled, carpet replaced. “The registered person must ensure that suitable and appropriate door closures are fitted where there is a need for doors to remain open, they Ashleigh House Nursing Home DS0000017177.V311705.R01.S.doc Version 5.2 Page 18 must be linked to the fire alarm system to close effectively when the fire alarm is activated”. At the time of this inspection it was noted that no doors were lodged open inappropriately – the Inspector was told that the homes policy is to maintain this practice so that electrical closures linked to the fire alarm system would be unnecessary. “The registered person must ensure that new bedding is purchased”. New sheets and duvet covers have been purchased. However, the new duvet covers were seen to still be in the delivery boxes despite the fact that much of the bedding seen was of very worn appearance. It is a ‘Requirement’ of this Inspection that new bedding materials to be put into use. The following ‘Requirements’ had not been met: “The registered person must ensure that service users are fully consulted and involved in the redecoration of their own bedrooms”. “The registered person must ensure that the bedroom furniture provided is in good order and fit for the purpose”. Review of Resident’s care plans, and discussion with 3 randomly selected Residents, provided no evidence of their involvement in influencing the décor of their bedrooms, or choice of bedding or furnishings. This ‘Requirement’ remains and, in addition, it is ‘Recommended’ that, when it is within a service users’ individual capabilities, they are directly involved in the choice and purchase of bedding items for their personal use. At the previous Inspection (11 August 2006) it was noted: “The complete home, communal and private areas, are in urgent need of capital investment to upgrade the home to provide a clean, comfortable and pleasant environment in which to live. The carpets in the corridors are very worn, dirty and shabby, some chairs have been replaced in the smoking room with equally unsuitable replacements. The inspector was informed that the floor covering in the smoking room is unsuitable as it is very slippery when wet. This was discussed with the acting manager and a full assessment of risk and the action to be taken to reduce the risk will be undertaken. The bed linen on one service users bed was dirty and very soiled and the pillow in another room needed replacing. Chairs, wardrobes and chest of drawers in service users bedrooms were soiled, broken and old”. Ashleigh House Nursing Home DS0000017177.V311705.R01.S.doc Version 5.2 Page 19 It was evident at this inspection that these issues have not been addressed. In addition it was seen that some mattresses are also in need of urgent replacement. It is a ‘Requirement’ of this Inspection that a refurbishment/redecoration programme is established together with achievement target dates, which must be agreed with CSCI. Ashleigh House Nursing Home DS0000017177.V311705.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Staff continue to be supported to attend training appropriate to their role. The home has a robust recruitment procedure, which ensures pre employment checks are completed on all staff prior to commencement of post. Supervision and appraisal of staff is not being carried out. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A discussion with the acting manager relating to on going training provided up to date information about courses completed by staff and courses due to be completed in the near future. Unfortunately not all courses attended by the staff group were evidenced by attendance certificates. This was also true of staff that had carried out mandatory training. Individual examples were given to the acting manager during the case tracking of both new and long term staff employed at the home. Courses due to be completed by staff are as follows; acting manager – abuse training for trainers 15/09/06 and introduction to management 2/3/6/ Novemeber/06, two staff to attend adult protection, recognising and reporting, four staff to attend basic food hygiene date and Ashleigh House Nursing Home DS0000017177.V311705.R01.S.doc Version 5.2 Page 21 venue to be arranged, fourteen staff to attend emergency first aid on 11/10/06, 18/10/06, 15/11/06 and 8/12/06, one staff member to attend first aid refresher training on 23/11/06 and 24/11/06, three staff to attend fire risk assessment, two staff to attend disability equality training 8/11/06 and 9/11/06, three staff to attend mental health awareness two day course date and venue to be arranged, four staff to attend ageism training 6/12/06, two staff to attend infection control study day date and venue to be arranged, ten staff to attend basic foundation in health and safety certificate 10/01/07, 21/02/07 and 13/03/07, three staff to attend moving and handling inanimate objects 17/01/07, two staff to attend 9,16,23,30, January 2007. Two new members of staff have been appointed since the last inspection. The files of both members of staff were examined to monitor recruitment practice. Both files were well organised and seen to contain all necessary pre employment checks prior to the individuals commencing employment. Through discussion with the acting manager it was confirmed that no progress has been made in relation to the supervision and appraisal of staff. This is due to the absence of a manager and the limited hours worked by the acting manager. The rota was provided to inspectors for the day of the inspection to 24th September. It was stated by the acting manager there is usually one RMN on the floor in the morning and afternoon plus three carers, and one RMN on the floor plus one carer at night. It was noted that staffing levels were maintained according to agreed levels. Ashleigh House Nursing Home DS0000017177.V311705.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Urgent action is needed to the future managerial arrangements to ensure that the home can fulfil its stated purpose and meet the needs of all the people living at the home. Lack of fundamental health and safety checks potentially leaves service users at risk. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The acting manager works Mon – Fri 9-3pm and is available outside of these times by telephone. It was evident through inspection that these arrangements are insufficient and an appointment of a manager is urgently required. There is insufficient time being given to the management role in order to ensure that staff are complying with policies and procedures, care plan documentation and supporting staff through supervision and appraisal. Ashleigh House Nursing Home DS0000017177.V311705.R01.S.doc Version 5.2 Page 23 The views of service users/relatives/representatives and other interested parties are not involved in any quality assurance audit system. For quality assurance and monitoring purposes the views of family, friends and health care professionals need to be sought on how the home is achieving the goals for service users. Mr Wardle the Responsible Individual visits the home weekly to deliver the petty cash to the acting manager. Examination of records relating to bath water temperatures, fridge freezer temperatures and the checking of random sample bath water temperatures showed them to be in accordance with Regulations and National Minimum Standards. The Home was found to be generally safe environment. Noteworthy exceptions were: The room in the extension labelled ‘Store S/H’ which is used to store paint was not locked. It is a ‘Requirement’ of this Inspection the door to this room is locked when not being accessed and that a notice to this effect is posted on the door. The door to the laundry room was unlocked. It is accepted that a number of Residents have been ‘Risk Assessed’ as being able to safely carry out their own laundry unsupervised. However, Residents who are not assessed as being so capable could be at risk from substances (detergents, fabric conditioners) and also at risk from scalding due to the hot water tap serving the main sink, which is not thermostatically controlled. It is a ‘Requirement’ of this Inspection that a protocol is developed, and instigated, which enables ‘Risk Assessed’ Resident to carry out their personal laundry whilst removing any risk to other Residents. Records relating to fire safety checks were not up to date and discussed with the acting manager at the time of the visit. It is a ‘Requirement’ of this inspection that all checks relating to fire safety must be carried out in line with fire regulations. The hot water system in service user bedrooms was randomly tested during a tour of the home and evidenced that problems with the hot water system continue. It is a ‘requirement’ of this inspection that the hot water system is in full working order. Ashleigh House Nursing Home DS0000017177.V311705.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 Adults 18-65 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 2 x 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 x 26 1 27 x 28 x 29 x 30 1 STAFFING Standard No Score 31 x 32 2 33 x 34 3 35 3 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 2 15 3 16 1 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x 2 x 1 x 1 x x 2 x Ashleigh House Nursing Home DS0000017177.V311705.R01.S.doc Version 5.2 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4,5, Schedule 1 Requirement The statement of purpose must contain all of the required elements as detailed in schedule 1 of the younger adults care home regulations 2001. A service user guide must me made available to all prospective service users and be made available for inspection at all times. Both documents must be reviewed at regular intervals to ensure they contain the correct and current information This is now outstanding from previous inspections. Time scale of 21/06/05 not met. The registered person must ensure that the service users and/or representatives are fully involved with the care planning process to include the agreement of any identified changes This is now outstanding from previous inspections. Time scale of 21/06/05 not met. DS0000017177.V311705.R01.S.doc Timescale for action 12/12/06 2. YA6 15(1)(2) 12/12/06 Ashleigh House Nursing Home Version 5.2 Page 26 3. YA6 15(1) The care plan must detail the current and anticipated care needs and how these needs will be met. This is now outstanding from previous inspections. Time scale of 21/06/05 not met. The registered manager must ensure that service users have as part of their basic contract price the option of a minimum seven day holiday outside of the home, which they help to choose and plan. Time scale of 31/08/05 not met. The registered person must ensure that subject to a full assessment of risk, service users are offered a key to the front door. This is now outstanding from previous inspections. Time scale of 21/06/05, 21/03/06, 31/03/06 & 31/05/06 not met. A comprehensive policy and procedures document for the safe handling of medicines must be formulated and it must be ensured that all of the staff involved in the handling of medication are aware of the new document and adhere to them. Not inspected on this occasion. The home must obtain written conformation from the residents’ GP that the Homely Remedies protocol is safe to use for each resident. Not inspected on this DS0000017177.V311705.R01.S.doc 12/12/06 4. YA14 16(2)(m)(n) 12/12/06 5. YA16 13(4)(b)(c) 12/12/06 6. YA20 13(2) 07/10/06 7. YA20 13 (2) 07/10/06 Ashleigh House Nursing Home Version 5.2 Page 27 occasion. 8. YA20 1(2) A weekly audit of the residents’ medication and the MAR charts must be commenced to ensure that the residents’ receive their medication as prescribed and any anomalies are dealt with effectively at the time of the incident. Not met on 11/08/06. All medicines administered/non administered must be recorded immediately after the transaction with either a signature or a defined abbreviation in order to eliminate gaps in the administration record. The completion of the Controlled Drugs register must also be completed after the administration has taken place. Not inspected on this occasion. The administration of “when required” medication must be supported with a written explanation of the event. Further details of when “when required” Lorazepam and Haloperidol should be administered must be sought from the prescriber. Not met on 11/08/06. Generic abbreviations used to identify why certain medication had not been administered must be properly defined Not inspected on this occasion. All “as directed” doses must be confirmed in writing by the prescriber and the MAR sheets must be amended DS0000017177.V311705.R01.S.doc 17/09/06 9. YA20 13(2) 17/09/06 10. YA20 13(2) 17/09/06 11. YA20 13 (2) 17/09/06 12. YA20 13 (2) 17/09/06 Ashleigh House Nursing Home Version 5.2 Page 28 13. YA20 13(2) 14. YA20 13(2) 15. YA24 No equivalent regulation accordingly. Not inspected on this occasion. The Controlled Drugs cabinet 17/09/06 must be secured to the wall properly. Not inspected on this occasion. The Aranesp injections found 12/09/06 in the fridge must be discarded immediately and a new supply obtained before the 14th August 2006. The home must ensure that this new supply is stored at the correct temperature. The registered person must 31/10/06 devise a refurbishment/ redecoration programme, which together with proposed achievement target dates, must be presented to CSCI for agreement. The registered person must ensure that service users are fully consulted and involved in the redecoration of their own bedrooms. The registered person must ensure that the bedroom furniture provided is in good order and fit for the purpose. The registered person must ensure that the bedroom furniture provided is in good order and fit for the purpose. (1) 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 (a) ensure that at all times 30/11/06 16. YA26 12(2) 17. YA26 1692)(c) 31/12/06 18. YA26 16(2)(c) 31/12/06 19. YA32 18(1)(a) 12/10/06 Ashleigh House Nursing Home DS0000017177.V311705.R01.S.doc Version 5.2 Page 29 20. YA36 18(2) 21. YA37 8(1) 22. YA39 24(1) 12(1) 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. Timescale 01/09/06 not met All staff must have formal recorded supervision with their line manager at least six times per year together with an annual appraisal of their work performance. The registered person must ensure that the application for a registered manager is forwarded to Commission for Social Care Inspection. This is outstanding from previous inspections. Previous timescale 30/09/06 not met. For quality assurance and monitoring purposes the views of family, friends and health care professionals need to be sought on how the home is achieving the goals for service users. This is outstanding from previous inspections. Time scale of 21/06/05 not met. The registered person must ensure that the water system is in full working order. The door to store room S/H is locked when not being accessed and that a notice to this effect is posted on the door. 12/12/06 30/09/06 01/10/06 23. 24. YA42 YA42 23(2)(p) 13(4)(a)(c) 12/10/06 12/10/06 25. YA42 13(4)(a)(b)(c) The registered manager must ensure a protocol is DS0000017177.V311705.R01.S.doc 12/10/06 Ashleigh House Nursing Home Version 5.2 Page 30 developed, and instigated, which enables ‘Risk Assessed’ service users’ to carry out their personal laundry whilst removing any risk to other service users. 26. YA42 23(4) The registered manager must ensure that all checks relating to fire safety are carried out in line with fire regulations. 12/10/06 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 YA20 Good Practice Recommendations It is recommended that in situations where Residents are recurrently non-compliant in taking prescribed medicines, the manager ensures that the prescribing clinician is aware of this, with a view to a review of such individual’s medicines regimes. Ashleigh House Nursing Home DS0000017177.V311705.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ashleigh House Nursing Home DS0000017177.V311705.R01.S.doc Version 5.2 Page 32 - 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. 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