Inspection on 20/04/06 for Ashleigh House Nursing Home

This inspection was carried out on 20th April 2006.

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

The inspector 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 22 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashleigh House Nursing Home 09/08/08

Ashleigh House Nursing Home 12/09/06

Ashleigh House Nursing Home 30/11/05

Ashleigh House Nursing Home 21/06/05

Ashleigh House Nursing Home 05/01/05

Ashleigh House Nursing Home 18/05/04

Ashleigh House Nursing Home 09/02/04

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Ashleigh House Nursing Home Ashleigh House 107 Gorge Road Coseley Wolverhampton West Midlands WV14 9RH Lead Inspector Joy Hoelzel Unannounced Inspection 20th April 2006 09:45 Ashleigh House Nursing Home DS0000017177.V292200.R01.S.doc Version 5.1 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.V292200.R01.S.doc Version 5.1 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.V292200.R01.S.doc Version 5.1 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.V292200.R01.S.doc Version 5.1 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. 30th November 2005 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. Ashleigh House Nursing Home DS0000017177.V292200.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection is the first of key inspections for 2006/07 and took place over eight hours on Thursday 20th April 2006. Two additional monitoring visits were conducted following the statutory inspection in November 2005. Each of the monitoring visits evidenced that the improvements to care planning, staffing levels, day to day management and the daily living for service users at the home continue. The acting manager has developed and maintained some stability for service users and staff living and working at the home. Nineteen service users were resident at the time of this inspection, with staffing numbers maintained at the agreed levels. The acting manager was on the premises and offered his full cooperation during the day. Three case files were selected for case tracking, relevant documents were inspected, discussions were held with nine service users, six members of staff and acting manager, observation was made of the various daily activities and a tour of the premises was conducted. What the service does well: What has improved since the last inspection? Improvements have been made in care planning, decision making and the general lifestyle of the people living at the home. The acting manager has developed a more stable and settled environment. The training and development needs of staff have been identified with arrangements made for courses to be accessed during the year. Staffing numbers are being maintained in line with the agreed levels. Ashleigh House Nursing Home DS0000017177.V292200.R01.S.doc Version 5.1 Page 6 Service users stated that more social, leisure and recreational activities are being made available and improvements have been made to the provision of meals. The effectiveness and continuity of the improvements must be maintained and will be monitored through future regulatory inspections. What they could do better: Eleven of the twenty requirements issued following the inspection in November 2005 have not been fully complied with, a further eleven requirements have now been issued. The home is in urgent need of complete redecoration and refurbishment to ensure that a good standard of living in a safe environment is offered and meets the diverse needs of all people within the home. The statement of purpose must accurately reflect the services and facilities that the home purports to offer. Service users commented that they would like the opportunity to go on an annual holiday. Further developments are needed to enhance and expand an independent lifestyle based on the individual’s needs and capacity. Further improvements are required to ensure a safe system of medication is operable. All people living and working at the home must be informed of the complaints and adult protection procedures. The recommendations from the fire officer must be fully complied with. Arrangements must be introduced to ensure the health, welfare and safety of individual’s is upheld. Systems must be in place for adequately supervising staff at least six times a year. A suitably qualified person must be identified for the role of registered manager. Further improvements and developments are needed for monitoring the quality of the service. Ashleigh House Nursing Home DS0000017177.V292200.R01.S.doc Version 5.1 Page 7 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.V292200.R01.S.doc Version 5.1 Page 8 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.V292200.R01.S.doc Version 5.1 Page 9 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): 2 Quality in this area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory admissions procedure; the effectiveness of the procedure will be measured over a period of time. EVIDENCE: Both statement of purpose and service users guide have been reviewed and contain the current information. The statement of purpose must accurately reflect the services and facilities that the home purports to offer (please see comments in Section 3 Lifestyle). The case file of the person most recently admitted to the home includes a full assessment of need from the health and social services. The acting manager stated that this person visited the home for a full day prior to making the decision to move in. It was not possible for the acting manager to visit in the person’s previous placement prior to arranging for her to visit Ashleigh House. A four-week trial period has just been completed with the decision made for a permanent placement. A care plan was developed based on the pre admission assessment information and was reviewed and updated during the trial period. Ashleigh House Nursing Home DS0000017177.V292200.R01.S.doc Version 5.1 Page 10 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. Quality in this area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements have been made to supporting people with decision making with their individual needs and choices; the effectiveness and continuity of the recent changes will be measured in due course. EVIDENCE: Three care plans were selected for inspection. The acting manager has introduced new documentation for all care plans. The plans have been reviewed with the full involvement of the service users. A key worker system is in operation and a weekly report is made in the care plan from the key worker. This is in addition to the daily reports and evaluations made by the nursing staff. All care plans are being reviewed on a monthly basis, staff commented that each service user is involved in the process; the documentation does not contain this information. It was recommended that the documentation be amended to include a section for the service users signature. The discussions and interactions between the staff and service users as to their plans for the activities of the day were observed. People were attending Ashleigh House Nursing Home DS0000017177.V292200.R01.S.doc Version 5.1 Page 11 College, going to a drop in centre at the local church, shopping or staying at the home. Risk assessments are carried out when identified, recorded in the care plan and reviewed at three monthly intervals. The manager was observed to be explaining and emphasizing the procedure for staying safe when a person was planning to go out of the home and into town. This had previously been identified as a risk to this person; following assessments and discussions the procedure for staying safe was agreed with the service user and recorded in the care plan. Ashleigh House Nursing Home DS0000017177.V292200.R01.S.doc Version 5.1 Page 12 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): 12,13,15,16,17 Quality in this area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements have been made with supporting people at the home to establish and maintain their own preferred lifestyles. The effectiveness and continuity of the improvements must be maintained and will be monitored. EVIDENCE: One service user was preparing to go to the local college and stated that he thoroughly enjoyed the experience in particular using the library. The occupational therapist had undertaken an assessment for a person selected for case tracking. A full report had been prepared 07/04/06, with the comment of a therapeutic programme to be developed based on this assessment. The acting manager and care staff discussed the difficulties with some service users being reluctant or unmotivated to partake in the activities arranged. During the afternoon of the inspection a keep fit session had been organised. This was observed to be great fun with lots of laughter and chat during the session. Service users appeared to be thoroughly enjoying this activity. Ashleigh House Nursing Home DS0000017177.V292200.R01.S.doc Version 5.1 Page 13 One care staff has been allocated the additional duties of arranging activities and was full of enthusiasm, she commented that she had concerns that this level of activity would be allowed to continue in the future. The recently revised statement of purpose states ‘We aim to help service users exercise the opportunity to select from a range of options in all aspects of their lives – Offering service users a wide range of leisure and therapeutic activities from which to choose. Providing a range of leisure and recreational activities to suit the tastes and abilities of all service users and to stimulate participation’. Two service users stated that they have seen improvements in the frequency of the activities but felt that more would be beneficial especially the opportunity to go on holiday. This has been included in discussions at the community meeting and a letter has been sent to all service users asking for their ideas on the preferred holiday destination. The acting manager stated that the options would be discussed at the next community meeting. All service users are offered a key to their own bedroom, and most service users now have the key. A letter has been sent to all service users asking if they do not wish to have a key to the front door. The wording of the letter does not give the service users a true choice to this facility. The acting manager discussed the reasoning for not giving a front door key and stated that if service users were out late they could access the home by ringing the front door bell and waiting for staff to answer, there is also the issue of keys getting lost and the potential for a security issue. The statement of purpose states ‘ Privacy…………..Providing individual keys not only for the service users own bedroom door, bedside cabinet but also for the front door in order to promote independence’. Two service users stated that they felt the meals had improved and that there was now more choice. Five service users comment cards have been returned with one person indicating a satisfaction with the meals making an additional comment ‘ I have enough choice’. Three people indicated that sometimes they like the meals at the home; one person indicated that usually the meals were satisfactory. One person made an additional comment ‘ Improve it, more choice’. One service user had requested a favourite dessert of rhubarb; the cook had prepared the rhubarb crumble that was enjoyed by all. The cook stated that personal preferences are prepared when ever possible. One person prefers to dine alone; this request is facilitated with serving the meal either before or after other people have eaten. The appearance of the dining room has improved with the purchase of table linen. Some service users are now offered the opportunity to prepare and cook their evening meal. At the time of the inspection one service user was preparing his own meal for the first time and was looking forward to the experience. Ashleigh House Nursing Home DS0000017177.V292200.R01.S.doc Version 5.1 Page 14 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): 18,19,20 Quality in this area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements have been made with supporting people with their personal and healthcare requirements. Some amendments are needed to the procedure for the administration of medication to ensure that a safe system is operable. EVIDENCE: The three care plans each included details of a person personal preference for the amount of personal support they require. Service users spoken with stated that they are able to go to bed and rise in the mornings at time suitable to them. Staff were observed during the course of the day offering support and guidance. All service users are registered with a local Gp, and are supported to manage their own healthcare/medical treatment. All service users now have a consultant psychiatrist and have had a full review of their mental health needs and medication during the last six months. The acting manager stated that good working relationships with the mental health service have been developed and maintained. One registered nurse has been delegated to oversee the medication administration procedures. All medications received into the home are now Ashleigh House Nursing Home DS0000017177.V292200.R01.S.doc Version 5.1 Page 15 being recorded on the Medication Administration Record chart with a monthly audit undertaken by the acting manager. A twenty-eight day prescribing regimen is operational using a monitored dose system with the additional use of bottles and boxes of medication. Some gaps on the Medication Administration Record chart were observed where the nurse had not signed when the medication had been administered. The date of opening eye drops, and on tubs and tubes of external preparations had not placed on the box; the nurse in charge was unable to establish if the preparations were within the use by date after opening. The contents of the medication cupboards have not been reorganised so that each service users medication is stored together in one area to reduce the risk of medication being administered wrongly. The prescribing label of some external preparations was missing it was not possible to establish for whom the preparations had been prescribed. Ashleigh House Nursing Home DS0000017177.V292200.R01.S.doc Version 5.1 Page 16 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 Quality in this area is poor. This judgement has been made using available evidence including a visit to this service. Some improvements have been made to protecting people from harm, further improvements are required to ensure that all people living and working at the home are aware of how and to whom they are able to discuss their concerns with. EVIDENCE: The complaints procedure has been updated to include the details of Commission for Social Care Inspection and is included in the statement of purpose and service user guide. Two complaints have been made to the acting manager since August 2005; an enquiry was carried out using the homes own complaints procedure, with one complaint being partially substantiated and the other not upheld. Of the five service users comment cards received three people indicated that they always, sometimes or usually knew how to make a complaint. One person made an additional comment ‘ I don’t always know how to make a complaint but I would talk to a staff member’. An adult investigation procedure is currently ongoing. Information emerging from that investigation suggest that complaints and concerns about the welfare of service users have not been responded to appropriately and therefore people have not been offered adequate protection form harm. Training for staff in adult abuse awareness and whistle blowing has been arranged for April and November 2006. The acting manager is currently having discussions with the Wolverhampton Adult Protection manager in regard to future training needs for the staff. Ashleigh House Nursing Home DS0000017177.V292200.R01.S.doc Version 5.1 Page 17 Ashleigh House Nursing Home DS0000017177.V292200.R01.S.doc Version 5.1 Page 18 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 Quality in this area is poor. This judgement has been made using available evidence including a visit to this service. There has been little change to the décor, and only limited changes to the furnishings. The lack of recent investment for replacing furniture and fittings is placing service users at risk, and is not creating a pleasing and pleasant environment to which to live. EVIDENCE: Limited redecoration of communal areas and replacement of furniture has been carried out since August 2005. This programme has now ceased the acting manager was unable to say when the programme will begin again. 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. Ashleigh House Nursing Home DS0000017177.V292200.R01.S.doc Version 5.1 Page 19 Chairs, wardrobes and chest of drawers in service users bedrooms were soiled, broken and old. The door catch on the tumble dryer is broken; a basket is being used to keep the door closed when the machine is in use. No communal or doors to private areas were observed to be wedged open, however the acting manager stated that the required door closures had not been fitted on the doors that had previously been identified. The communal areas appeared to be a lot cleaner and more hygienic than in recent times. The staff must be commended for their continued endurance for improving this within the confines of the lack of resources and any major investment. Ashleigh House Nursing Home DS0000017177.V292200.R01.S.doc Version 5.1 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 Quality in this area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements have been made with facilitating and developing the staffs knowledge, assurances are required that this level of activity will continue. EVIDENCE: The acting manager provided a current list of all staff at the home with the pre inspection questionnaire. Staffing levels are being maintained in line with the previously agreed numbers, the acting manager is supernumery and is supported by registered mental nurses and care staff. The personnel files for the four new staff members are currently at the administration office at another premise being organised. The personnel file of a long serving member of staff evidenced that references and criminal record bureau disclosures checks have been carried out. A training matrix and plan for 2006 has been developed with provisional dates being made for all core topic areas and some specialist subjects. A programme for training in Mental Health has been developed with regular sessions arranged for staff. Four care staffs have been enrolled and are currently working towards National Vocational Qualification level 2 in care. One staff member discussed the recent training received in fire safety and stated that she would shortly be attending training in Adult Protection. Ashleigh House Nursing Home DS0000017177.V292200.R01.S.doc Version 5.1 Page 21 Formal staff supervision has not being conducted systematically and is now outstanding for all levels of staff. Ashleigh House Nursing Home DS0000017177.V292200.R01.S.doc Version 5.1 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 Quality in this area is poor. This judgement has been made using available evidence including a visit to this service. Urgent action is required to the future managerial arrangements to ensure that the home can fulfil its stated purpose and meets the needs of all people living at the home. The continued lack of investment to the replacement of essential equipment is not creating a pleasant environment in which to live and work. EVIDENCE: The acting manager is leaving the home at the end of April and was unable to confirm the future managerial arrangements after he leaves. Staff and service users are anxious and concerned about this due to the previous instability and difficulties experienced during 2005. Questionnaires on living in the home were issued to all service users and included sections on catering and food, personal care and support, daily living, premises and management. The results have been analysed with the findings planned for discussion at future service users meetings and will also be used to aid the many improvements needed at the home. Ashleigh House Nursing Home DS0000017177.V292200.R01.S.doc Version 5.1 Page 23 The responsible individual visits the home at least monthly and prepares a report on the findings a copy of which is given to the acting manager and sent to Commission for Social Care Inspection. The hot water temperature was randomly tested during the tour of home and evidenced that problems with the hot water system continue. The hot water in the first floor bathroom ranged at 48-49 degrees centigrade. In the other bathrooms and service users bedrooms the temperature ranged from 33- 39 degrees centigrade. The first floor bathroom was immediately taken out of use because of the increased risk of scalding to service users. The heating engineer was contacted with a plan for remedial work to be carried out the following day to maintain a hot water temperature of 43 degrees in all areas accessible to service users. The problems identified by the independent contractors, and reported on during the inspection in November 2005, when assessing the risk of legionella and the hot and cold water systems have not been attended to hence the continual problems with maintaining a safe and satisfactory hot water temperature. Ashleigh House Nursing Home DS0000017177.V292200.R01.S.doc Version 5.1 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 3 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 2 23 1 ENVIRONMENT Standard No Score 24 1 25 X 26 2 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 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 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 1 X Ashleigh House Nursing Home DS0000017177.V292200.R01.S.doc Version 5.1 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 Requirement Timescale for action 31/05/06 2 YA14 4(1)(a)(b)(c) The statement of purpose must accurately reflect the services and facilities that the home purports to offer. 16(2)(m)(n) 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. Timescale of 31/03/06 not fully met 13(4)(b)(c) 31/05/06 3 YA16 The registered person must 31/05/06 ensure that subject to a full assessment of risk, service users are offered a key to the front door. Time scale of 21/06/05 and 31/03/06 not met. The Medication Administration Record chart must be completed at the time of the medication administration The date of opening eye drops and external preparations DS0000017177.V292200.R01.S.doc 4 YA20 17(1)(a) Schedule 3 (k) 13(2) 31/05/06 5 YA20 31/05/06 Ashleigh House Nursing Home Version 5.1 Page 26 6 YA20 13(2) 7 8 YA20 YA22 13(2) 22 9 YA23 18(1)(a)(c) must be placed on the package. The contents of the medication cupboards must be reorganised for each individual to reduce the risk of wrongly administering the medication. All medications received into the home must have an appropriate prescribing label The registered person must ensure that all people living at working at the home are aware of the complaints procedure and to whom they can discuss their concerns. The registered person must ensure that all staff receive training in abuse awareness and whistle blowing Timescale of 31/03/06 not fully met. The registered person must ensure that suitable and appropriate door closures are fitted where there is a need for doors to remain open, they must be linked to the fire alarm system to close effectively when the fire alarm is activated. Timescale of 01/01/06 not fully met. 31/05/06 31/05/06 31/05/06 31/05/06 10 YA24 23(4) 31/05/06 11 YA24 13(4)(a)(c) 12. YA24 23(2) The registered person must 31/05/06 ensure that action is taken to reduce the risk of injury through slipping on the floor in the smoking room when it is wet. The registered person must 31/05/06 ensure that all furniture for communal use is in good order and meets the required safety standards. Time scale of 31/08/05 and 30/12/05 not met. DS0000017177.V292200.R01.S.doc Version 5.1 Page 27 Ashleigh House Nursing Home 13 YA24 No Equivalent Regulation 16(2)(c) 12(2) 14 15 YA24 YA26 The home must have a planned maintenance and renewal programme for the fabric and decoration of the home, with records kept. People living at the home must be provided with clean and appropriate bed linen. The registered person must ensure that service users are fully consulted and involved in the redecoration of their own bedrooms. Timescale of 30/12/05 not fully met. The registered person must ensure that the bedroom furniture provided is in good order and fit for the purpose. Timescale of 30/12/05 not fully met. 31/05/06 31/05/06 31/05/06 16. YA26 16(2)(c) 31/05/06 17 YA34 7, 9, 19 Schedule 2 18(1)(c) (i)(ii) 18 YA35 Information and documents 31/05/06 relating to people working at the home must be available for inspection when requested. The registered person must 31/05/06 ensure that training in all core and specialist topics and updates are arranged for all staff. This is outstanding from previous inspections. Time scale of 21/06/05 and 30/12/05 not fully 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 DS0000017177.V292200.R01.S.doc 19 YA36 18(2) 31/05/06 20 YA37 8(1) 31/05/06 Ashleigh House Nursing Home Version 5.1 Page 28 forwarded to Commission for Social Care Inspection. Time scale of 30/12/05 not met. 21 YA39 24(1) 12(1) For quality assurance and 31/05/06 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 and 31/03/05 not fully met. The registered person must ensure that the central heating and hot water systems are in full working order. Repairs and /or replacement are urgently required. Timescale of 30/12/05 not fully met. 31/05/06 22 YA42 23(2)(p) 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 YA6 Good Practice Recommendations It was recommended that the care planning documentation be amended to include a section for the service users signature. Ashleigh House Nursing Home DS0000017177.V292200.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Wolverhampton Area Office 2nd Floor St. Davids Court Union Street Wolverhampton WV1 3JE 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. 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