Inspection on 21/06/05 for Ashleigh House Nursing Home

This inspection was carried out on 21st June 2005.

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

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

Other inspections for this house

Ashleigh House Nursing Home 09/08/08

Ashleigh House Nursing Home 12/09/06

Ashleigh House Nursing Home 20/04/06

Ashleigh House Nursing Home 30/11/05

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 107 Gorge Road Coseley Wolverhampton WV14 9RH Lead Inspector Joy Hoelzel Unannounced 21st June 2005 11:00 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 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 Stationary 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 E56 000017177 Ashleigh House V229719 UI 010605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Ashleigh House Address 107 Gorge Road, Coseley, Wolverhampton, WV14 9RH Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01902 880886 01902 887738 Ashleigh Healthcare Ltd Mr Ramachelowan Care Home with Nursing 19 Category(ies) of Mental Disorder (19) registration, with number of places Ashleigh House E56 000017177 Ashleigh House V229719 UI 010605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1) Recovering mentally ill aged 19 years to 60 years. 2) The home can accomodate one named service user over the 60 years age limit. Date of last inspection 05/01/2005 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 accommodation of 17 single occupancy bedrooms and one twin room. There is a dining room, two lounges and a designated smoking lounge. Ashleigh House E56 000017177 Ashleigh House V229719 UI 010605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over five hours on Tuesday 21st June 2005 and is the first of the statutory inspections for 2005/06. Nineteen service users were resident at the time of inspection, staffing levels appeared to be at the agreed numbers as indicated on the staffing roster, but the actual people on the premises did not correspond. The registered manager was on the premises at the time of the inspection, supported by one care staff carrying out catering duties and one domestic staff carrying out care duties. A tour of the premises took place, three service users care plans were examined in depth, together with supporting documents and discussions were held with six service users and the manager. Five immediate requirements were issued at this inspection for urgent action to be taken in the following areas • • • • • The hot water temperatures must be controlled at around 43 degrees centigrade Adequate staffing levels must be maintained and the rota kept up to date. The damaged chairs in the smoking room to be removed All combustible material to be removed from the basement All service users money held on the premises on behalf of the individual must accurately correspond with the amount stated on the recording sheet. What the service does well: What has improved since the last inspection? Ashleigh House E56 000017177 Ashleigh House V229719 UI 010605 Stage 4.doc Version 1.30 Page 6 There is nothing to suggest that things have improved at the home since the last inspection, no changes have been made to any documentation and no investment has been made to improve the environment. 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 E56 000017177 Ashleigh House V229719 UI 010605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Ashleigh House E56 000017177 Ashleigh House V229719 UI 010605 Stage 4.doc Version 1.30 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 standard(s) 1,2,4 Little progress has been made to improve the admission procedure to ensure that a full assessment of need is undertaken prior to people moving into the home. Without this there is no assurance that care needs will be met. EVIDENCE: The statement of purpose and service user guide were unavailable at the time of the inspection. The registered manager stated that both documents have been updated but was unable to find them. The care plan of a service user recently admitted to the home was inspected and evidenced that the manager of the home undertook a pre - admission assessment of need. The form was not fully completed and did not contain the relevant information to enable an informed decision to be made as to the suitability of the placement. The registered manager stated that he did not have the opportunity to meet with the service user at the other placement when he visited. The registered manager also stated that the service user visited the home prior to making the decision to move in but there is no evidence to support this, either in the daily diary or care plan. The care plans inspected did contain a copy of the contract/terms and conditions with the home. The contract with the most recent service user was not fully completed. Ashleigh House E56 000017177 Ashleigh House V229719 UI 010605 Stage 4.doc Version 1.30 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 standard(s) 6,7,9 No changes or improvements have been made to the documentation and recording in the care plans. There is little evidence to suggest that the care provided has any relation to that written in the care plan. EVIDENCE: Each service user has a plan of care, which is generated from the pre admission assessments. The care plans are reviewed at regular intervals, one service user stated that he is not consulted or involved when changes to the plan are required. The care plan of the most recent service user was not fully completed to detail all care needs, neither were there risk assessments or management strategies for any challenging or problematic behaviour that may be presented. Another care plan detailed the care required as ‘developing cooking skills’, with a review of ‘supervised by staff whenever cooking’. The registered manager stated that this service user was supervised to make toast but was unable to say when this occurred and there is no record in the care plan of this activity taking place. The service users kitchen, at the time of the inspection was locked, inaccessible to service users and when inspected did not contain any items of food. One service user stated that he was unable to make drinks and had to Ashleigh House E56 000017177 Ashleigh House V229719 UI 010605 Stage 4.doc Version 1.30 Page 10 ask the staff if he wanted a drink outside of mealtimes, he stated that there is a ‘rule’ of ‘no kettles in rooms’ and does not have a fridge to keep drinks cool. Service users hold a community meeting; the next one planned for 19/06/05, to discuss issues within the home and then feedback the findings to the staff. One service user described the limitations imposed with living at the home and described the routine practice of the last drink being available at 10:30pm and having to go to the bedrooms by 11pm with no one allowed downstairs after that time. The smoking room is then locked and night staff use the sitting room as their base for the night. Ashleigh House E56 000017177 Ashleigh House V229719 UI 010605 Stage 4.doc Version 1.30 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 standard(s) 11,12,13,14,16,17 The standard of the meals provided is unsatisfactory, there is little to suggest that the meals are nutritious, well balanced or offer a healthy and varied diet. Very limited social, recreational or therapeutic activities are arranged; there is little evidence to suggest that service users views are being sought or that the activities are in any way stimulating. EVIDENCE: There was little evidence during the inspection of any therapeutic activity taking place. The registered manager explained the scheduled therapeutic programme, mainly vacuuming the dining room after meals, but explained the difficulties of motivating service users to comply. Service users explained that all meals are provided for them and that all laundry is attended to by the staff, the is no evidence to suggest that service users are being offered the opportunity to maintain and develop independent living skills. One service user commented that although she liked to do her Ashleigh House E56 000017177 Ashleigh House V229719 UI 010605 Stage 4.doc Version 1.30 Page 12 own washing, there were not enough pegs for her to hang the washing on the line. It is recognised that some service users may not wish to, or be able to involve themselves in personal development. Most service users at the time of the inspection looked unmotivated and uninterested in their day and focused mainly on smoking cigarettes. Some service users access the day centres, colleges and local shops. The registered manager explained the activities that are arranged for service users on their behalf, a planned trip to Kidderminster had to be cancelled due to an organised outing by the day centre. The group outing to Blackpool took place in June 2004. Service users commented that no holiday is being arranged for this year. No records are kept of the activities arranged or the service users participation. The more able service users are able to arrange activities independently but there is little evidence to suggest that the less able service users are being offered the opportunity of leisure, social or recreational activities. One service users stated that she would like to have more outings but explained the difficulties with having a limited budget. All service users are offered a key to their personal rooms but not a key to the front door. One service user stated that he rings the doorbell and waits for staff to answer if he is out late. The registered manager explained the procedure for dealing with service users mail, but it was observed that unopened mail was piled on the manager’s desk. One unopened letter was post marked 06/06/05, the date of the inspection being the 21/06/05. All meals are prepared and arranged by the catering staff, however on the day of the inspection a member of the care staff was preparing the midday meal because the cook was on annual leave. The registered manager arranges the menu with today’s menu being braised steak but corned beef hash and baked beans or cheese pie was available. Service users stated that the meals provided were ‘ok’, and ‘not too bad’. One service user stated that the food was the worst thing about living at the home. Another service user stated that they mainly have sandwiches for tea but the bread is nearly always stale, no fresh vegetables or fruit are available with the home only offering frozen vegetables and tinned fruit. The food store did not contain any fresh fruit or vegetables with the exception of a bag of potatoes. This was discussed at the time with the registered manager who thought that one serving per week of fresh fruit was sufficient. This issue was discussed with the registered manager at the last inspection in January 2005. One service user chooses to eat alone; this is arranged for him as he eats alone in the dining room before meals are served to other service users. Ashleigh House E56 000017177 Ashleigh House V229719 UI 010605 Stage 4.doc Version 1.30 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 standard(s) 18 There is little evidence to suggest that personal care is being offered in an appropriate or supportive way. EVIDENCE: Most service users appeared to be dishevelled and uncared for. One service user had an unpleasant odour, had dirty ill fitting clothes and shoes, the laces were missing from the shoes. This was brought to the registered managers attention he stated he personally helps this service user to bathe twice a week. Other service users were observed to have ill fitting shoes this being a potential risk of trips and falls. The care plan does not contain working records of person’s personal preferences and as discussed in the section of individual needs and choices the times for going to bed are determined by the working patterns of the staff. Ashleigh House E56 000017177 Ashleigh House V229719 UI 010605 Stage 4.doc Version 1.30 Page 14 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 standard(s) 23 The procedures in place do not protect service users from potential abuse. EVIDENCE: One complaint has been directed to the Commission for Social Care Inspection since January 2005 and was investigated through the vulnerable adults procedure. This being an allegation of physical abuse, following extensive investigations the allegation was unsubstantiated. The concerns, complaints standard will be inspected in depth at the next statutory inspection. Service users personal monies are kept on their behalf in a locked safe in the manager’s office. Each service user has an individual recording sheet detailing each transaction. However, it was observed that although there are individually named wallets in the safe these are not being used and the cash is being bundled together. An immediate requirement notice was issued to ensure that the actual amount of cash held and the total on the recording sheet must accurately correspond at all times. Ashleigh House E56 000017177 Ashleigh House V229719 UI 010605 Stage 4.doc Version 1.30 Page 15 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 standard(s) 24,26,30 There has been no change to the décor, and only limited changes to the furnishings. The lack of recent investment for replacing furniture and fittings, coupled with the apparent lack of maintenance and effective cleaning regimes, is placing service users at risk, and it does not create a pleasing and pleasant environment to live in. EVIDENCE: The home is a two-storey building with a recent extension to the side providing accommodation to seventeen adults. There is a large sitting room and dining room on the ground floor with one other smaller room and a dedicated smoking room in the other areas. The garden would benefit from a total overhaul and landscaping. The garden furniture appears to be very old, the white chairs and table are now green with age. The chairs in the ground floor sitting room and smoking room are torn and ripped with the inner foam being exposed. An immediate requirement was issued to remove the chairs from the smoking room as this posed a great risk of fire to service users and staff. Ashleigh House E56 000017177 Ashleigh House V229719 UI 010605 Stage 4.doc Version 1.30 Page 16 The registered manager was going to arrange for these chairs to be disposed of by burning in the garden, the inspector discouraged this practice and suggested an alternative way of disposal. The whole home had an unpleasant odour; service users commented that ‘the whole house smells’. A carpet in one of the bedrooms has been replaced but the carpet on the first floor landing remains despite being highlighted as needing replacing at the last inspection in January. The requirement from the inspection in January 2005 in relation to ensuring that procedures and systems are in place to keep the premises clean, hygienic and free from offensive odour is yet to be fully complied with. The registered manager has not yet developed a programme for the maintenance of the building or the renewal of fabrics and furnishings. This was a requirement at the inspection in January 2005. The basement was seen to be storing combustible materials; it was recommended at the recent fire officer’s visit that all combustible items be removed. An immediate requirement was issued to remove all such items from the basement as this poses a risk of fire. A wooden wedge was observed being used to keep open the fire-resisting door to the office lobby; a recommendation was made following the fire officers visit to fit an approved device if the door is required to be open. The shower tray in the ground floor bathroom is marked with cigarette burns and the sealant around the tray is loose. Ashleigh House E56 000017177 Ashleigh House V229719 UI 010605 Stage 4.doc Version 1.30 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34,35,36 The deployment and number of staff available is not sufficient to meet the needs of all service users. EVIDENCE: The staffing rota for the day did not correspond with the staff members on duty. At the time of the inspection on the premises was the registered manager, 1 care staff attending to catering duties, and one domestic attending to care staff duties. The registered manager explained that one care staff had called in sick and the cook was on annual leave, he had not attempted to arrange for an alternative cook to be available but relied on the care staff to fill this deficit. An immediate notice was issued to ensure that there are adequate numbers of all grades of staff available on the premises. The registered manager is rostered for all clinical duties and is not allocated any supernumery time; he states he works overtime to attend to his managerial responsibilities. Three staff personnel files were inspected and evidenced some deficits of the required checks. Two files did not have a second reference, a start date or record of the interview. One file did not contain proof of identification. All three files did not contain supervision or appraisal notes. Training records were not included in two files and very minimal in the third. Ashleigh House E56 000017177 Ashleigh House V229719 UI 010605 Stage 4.doc Version 1.30 Page 18 Documentation is available for the induction and foundation training, to skills in care specifications however the registered manager was unable to provide a completed copy. Ashleigh House E56 000017177 Ashleigh House V229719 UI 010605 Stage 4.doc Version 1.30 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39,42 The home is currently not well managed and, from evidence noted throughout this report, not in the best interest of service users. The lack of attention to identified hazards and risks do not promote and safeguard the health, safety and welfare of service users or staff. EVIDENCE: The registered manager is a registered mental nurse; the staffing rota indicates that he is rostered for all clinical duties. He states that he works overtime to attend to the managerial responsibilities. It was obvious that he is not allocated any supernumery time to attend efficiently or effectively to the role of the manager. The office desk was piled high with unopened mail, magazines and papers, the office in general was untidy and disorderly. As previously discussed in other sections of this report he was unable to produce the documents that were required for inspection. There was no evidence to suggest that the home has developed an effective quality assurance or monitoring system. Ashleigh House E56 000017177 Ashleigh House V229719 UI 010605 Stage 4.doc Version 1.30 Page 20 The hot water temperature was randomly sampled during the tour of the building and ranged from 31-40 degrees centigrade. The records indicated that the temperature fluctuates almost on a daily basis and is recorded at above 43 degrees centigrade on occasions. The registered manager is aware of the problems with maintaining a satisfactory hot water temperature. This is now outstanding from the previous two inspections; an immediate requirement was issued at this inspection for the registered manager to give this his urgent attention. Ashleigh House E56 000017177 Ashleigh House V229719 UI 010605 Stage 4.doc Version 1.30 Page 21 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 1 2 x 2 2 Standard No 22 23 ENVIRONMENT Score x 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x x x x x 1 Standard No 11 12 13 14 15 16 17 2 3 3 2 x 2 1 Standard No 31 32 33 34 35 36 Score x x 1 2 1 1 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ashleigh House Score 2 x x x Standard No 37 38 39 40 41 42 43 Score 2 x 2 x 2 2 x E56 000017177 Ashleigh House V229719 UI 010605 Stage 4.doc Version 1.30 Page 22 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 1 Regulation 4,5, Schedule 1. Requirement The statement of purpose and service users guide must now be produced in a suitable format and be available for all interested parties. This is now outstanding from the previous inspection. The registered person must ensure that a full assessment of need is carried out prior to a service users being admitted to the home. The registered person must ensure that all prospective service users are offered the opportunity to visit the home prior to admission. The statement of terms and conditions/contract must be fully completed as soon as practicable after admission. This is outstanding from previous inspections. The registered person must ensure that the service users and/or represetatives are fully involved with the care planning process to include the agreement of any identified changes The care plan must detail the Timescale for action Immediate 2. 2 14(1) Immediate 3. 4 14(1)(c ) Immediate 4. 5 5(1) Immediate 5. 6 15(1)(2) Immediate 6. 6 15(1) Immediate Page 23 Ashleigh House E56 000017177 Ashleigh House V229719 UI 010605 Stage 4.doc Version 1.30 7. 7 15(1() 8. 7 12(1)(a) 9. 9 13(4)(b) (c) 10. 11 12(1)(a) 11. 14 16(2)(m) (n) 12. 14 16(2)(m) (n) 13. 16 13(4)(b) (c) 14. 16 12(2) 15. 17 16(2)(i) current and anticipated care needs and how these needs will be met. The registered person must ensure that service users are encouraged and supported with making decisions about their every day lives. The registered person must ensure that staff working practices do not limit service users rights to make decisions. The registered person must ensure that risk is assessed prior to admission, any action that may need to be taken is fully detailed in the care plan together with risk amanagement strategies. The registered person must ensure that service users the opportunity to develop and maintain independent living skills if they so wish. The registered manager must ensure that service users have access to, and choose from a range of suitable and appropriate leisure activities. 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. The registered person must ensure that subject to a full assessment of risk, service users are offered a key to the front door. The registered person must ensure that the procedure for dealing with incoming mail is amended. The registered person must ensure that the meals provided are nutritious, varied and well Immediate Immediate Immediate Immediate Immediate 31st August 2005 Immediate Immediate Immediate Ashleigh House E56 000017177 Ashleigh House V229719 UI 010605 Stage 4.doc Version 1.30 Page 24 balanced 16. 17 16(2)(i) The registered person must ensure that fresh bread, fruit and vegetables are available at all times. The registered person must ensure that where needed, service users are guided and supported to maintain standards of hygiene. The registered person must ensure that the prodenure for dealing with service users personal money is robust and protects service users from financial abuse. This is outstanding form the previous inspection. An immediate requirement was issued at this inspection. The registered person must ensure that all furniture including garden furniture is in good condition and fit for the purpose. The registered person must ensure that the recommendations for the fire officers visit are fully complied with. An immediate requirement was issued at this inspection. The registered person must ensure that arrangements are in place for the safe disposal of unwanted items. The home must develop a planned maintenance and renewal programme for the fabric and decoration of the premises. This is outstanding from the previous inspection The registered manager is required to replace the carpet on the first floor landing. This is outstanding from the previous inspection. Immediate 17. 18 12(1)(a) (b) Immediate 18. 23 12(2)(3) Immediate 19. 24 23(2)(o) 31st August 2005 Immediate 20. 24 23(4) 21. 24 23(4)(a) Immediate 22. 24 No equivalent regulation Immediate 23. 24 12(1) 16(2)(j) (k) Immediate Ashleigh House E56 000017177 Ashleigh House V229719 UI 010605 Stage 4.doc Version 1.30 Page 25 24. 25. 24 30 23(2)(j) 16(2)(j) 26. 33 18(1) 27. 34 7,9,19 28. 35 18(1)(c ) (i)(ii) 29. 35 12(1)(a) (b) 18(1)(a) (c ) 18(2) 30. 36 31. 37 18(1)(a) The registered manager must repair/replace the shower tray in the ground floor bathroom. The registered manager must ensure that procedures and systems are in place to keep the premises clean, hygienic and free from offensive odour. This is outstanding from the previous inspection The numbers and skill mix of staff on duty (including domestic staff), day or night, ensure the following activities are carried out effectively and efficiently to meet the individual and collective needs of service users This is outstanding from the previous inspection. An immediate requirment was issued at this inspection The registered person must ensure that all information is kept in the staffs personnel file as detailed in Schedule 2 The registered manager must ensure that all staff receive training in the core and specialist topics relevant to the service user group. This is outstanding from the previous inspection. The registered person must ensure that all staff have induction and foundation training and that the appropriate documents are completed. The registered manager must ensure that all staff receive formal supervsion at least six times a year and a record kept. The registered person must ensure the the registered manager has allocated supernumery time to successfully manage the home and attend to a managers responsibilities. 31st August 2005 Immediate Immediate 31st August 2005 Immediate 31st August 2005 Immediate immediate Ashleigh House E56 000017177 Ashleigh House V229719 UI 010605 Stage 4.doc Version 1.30 Page 26 32. 37 10(3) 33. 39 24(1) 12(1) 34. 40 12(1) 35. 41 4(1)( c), 7,9,19, 17(1)(a), 17(2) Schedule 1,2 3 & 4 36. 42 13(4)(c) The registered manager must ensure that he accesses the required qualification in management and undertakes periodic training to maintain and update his knowledge and skills to manage the home. This is outstanding from the previous inspection. 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 the previous inspection. All policies and procedures must be monitored, dated, reviewed and amended on a regular basis. This is outstanding from the previous inspection. The registered person must ensure that all records (individual and home) are secure, up to date and in good order: and are constructed in accordance with the Data Protection Act 1998. This is outstanding from the previous inspection. The temperature of the hot water outlets accessible to service users must be maintained at a temperature close to 43 degrees centigrade This is outstanding from the two previous reports and must be attended to immediately. An immediate requirement was issued at this inspection. Immediate immediate Immediate Immediate Immediate Ashleigh House E56 000017177 Ashleigh House V229719 UI 010605 Stage 4.doc Version 1.30 Page 27 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 Good Practice Recommendations Ashleigh House E56 000017177 Ashleigh House V229719 UI 010605 Stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection 2nd Floor St Davids Court Union Street Wolverhampton 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 E56 000017177 Ashleigh House V229719 UI 010605 Stage 4.doc Version 1.30 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!