Inspection on 30/11/05 for Ashleigh House Nursing Home

This inspection was carried out on 30th November 2005.

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 20 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 20/04/06

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 30th November 2005 10:00 Ashleigh House Nursing Home DS0000017177.V270438.R01.S.doc Version 5.0 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.V270438.R01.S.doc Version 5.0 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.V270438.R01.S.doc Version 5.0 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.V270438.R01.S.doc Version 5.0 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. 21st June 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.V270438.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over five hours on Wednesday 30th November 2005 and is the second of the two statutory inspections for 2005/06. Nineteen service users were resident at the time of inspection; staffing levels are being maintained at the revised levels. The acting manager was on the premises and available throughout the inspection. A tour of the premises took place, two service users care plans were examined in depth, together with supporting documents and discussions were held with seven service users, three staff members and the manager. What the service does well: What has improved since the last inspection? A suitably qualified and experienced person has been recruited for the position of acting manager. Staffing levels have been increased. New documentation has been introduced for the admission procedure, care planning and terms and conditions/contracts. Arrangements have been made for each service user to be allocated a social worker and consultant psychiatrist. The kitchenette has been equipped and is kept well stocked with provisions ensuring service users can have refreshments at times suitable to the individual. Some communal areas of the home have been or are in the process of being redecorated. New procedures and protocols have been implemented in regard to handling service users personal monies, confidentiality and staff working. Improvements have been made to the menu and provision of food. Fresh fruit and vegetables are available daily. Ashleigh House Nursing Home DS0000017177.V270438.R01.S.doc Version 5.0 Page 6 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.V270438.R01.S.doc Version 5.0 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.V270438.R01.S.doc Version 5.0 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): 1,2,4 Although no new service users have been admitted to the home since June 2005, the home has revised the admissions policy; the effectiveness of the policy will be measured in the event of placements being offered to prospective service uses. The lack of a current and correct statement of purpose or service user guide does not assist prospective service users to make an informed choice of where they are to live. EVIDENCE: A copy of the statement of purpose was readily available, however, on observation the document does not contain all of the required information that is detailed in Schedule 1 of the Care Homes Regulations 2001. A review of the document is required to ensure that it contains the required, current and correct information. The acting manager stated that the service user guide is currently being reprinted, it is anticipated that it will be available shortly. The acting manager stated that there have been no new admissions since the last inspection in June 2005. The admission procedure has been revised and reviewed with the documentation for the preadmission assessments and trial visits prepared for use when needed. The statement of terms and conditions/ contract with the home and service users has been reviewed, the document is now available for new service users at the point if admission. Ashleigh House Nursing Home DS0000017177.V270438.R01.S.doc Version 5.0 Page 9 Ashleigh House Nursing Home DS0000017177.V270438.R01.S.doc Version 5.0 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): 6,7,10 Some improvements have been made to the care planning process; however, the delays in the lack of the completion may not be providing staff with all the information they need to fully meet the individuals’ needs. EVIDENCE: The allocated key nurses for each individual are reviewing all service users care plan files. New documentation is available and placed in the file. However on inspection only four risk assessments had been completed, which included the name of the assessor and date of the assessment but did not incorporate the frequency of a review or the date of the next assessment. One case file inspected included the signature of the service user indicating some involvement in the care plan for the planning and supporting with the activities of daily living. A daily report is being made by the key nurse and/or key worker, with the key worker documenting a separate weekly report. The activity and therapeutic programme has yet to be developed, the acting manager discussed the difficulties with service user participation and motivation in this area but stressed that the recent addition to the staff team of the occupational therapist would be of great assistance. It was discussed with the acting manager the importance of a complete, concise and current plan of care for each individual. It was agreed that each Ashleigh House Nursing Home DS0000017177.V270438.R01.S.doc Version 5.0 Page 11 key nurse would be instructed to fully complete at least one case file each within seven days with the remainder completed fully by the beginning of January 2006. A community meeting was held during the morning of the inspection with seven of the nineteen service users attending. This was a lively meeting offering service users the opportunity to discuss any problems they are encountering with life at the home, the social arrangements for the Christmas period and any special requests for the Christmas or daily menus. The kitchenette is now accessible to service users and is kept well stocked with drinks and snacks enabling service users to have refreshments at times suitable to themselves. Service users were observed to be using this facility during the time of the inspection. The acting manager stated that all service users now help themselves to breakfast, with a future plan of assisting and supporting service users to prepare their own meal during the evening. The main office is in the process of being revamped and reorganised, additional locking filing cabinets have been provided to ensure that records are kept safe and secure. The acting manager discussed the arrangements for maintaining confidentiality of both service users and staff and has introduced procedures and protocols to deal with this. Ashleigh House Nursing Home DS0000017177.V270438.R01.S.doc Version 5.0 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): 11,14,16,17 Improvements have been made to the ensuring good nutrition is maintained. Limited social, recreational or therapeutic activities are arranged. Further development and structure to the programme is required to support service users to lead full and active lives. EVIDENCE: The home has recently recruited an occupational therapist (2 hours per week) to assist with developing and arranging a therapeutic programme. The care plans inspected did not include any evidence of any occupational therapist involvement. The acting manager explained that plans are being developed but the implementation is slow and delayed due to time constraints of the OT involvement. Consultation is continuing with service users to plan a programme of activity, it is anticipated that by March 2006 the plans will be operational. The opportunity for service users to partake in planning and arranging a holiday outside of the home is in the early planning stage, the acting manager stated that a basic plan of venue and time of year for the holiday would be available in March 2006. I Some service users continue to attend the local day centres on a weekly basis, but most service users continue to arrange their own leisure and recreational Ashleigh House Nursing Home DS0000017177.V270438.R01.S.doc Version 5.0 Page 13 activities. During the inspection service users at the home were either in their own bedrooms, watching television or in the smoke room. Very little other structured activity was observed. Service users are now being encouraged and assisted to deal with their own laundry, staff are allocated on a daily basis to help with this task. The acting manager explained that the a new lock on the front door will be fitted during the redecoration programme of the hall, service users will then be offered a key to the door. Improvements have been made to the menu, two service users stated that they enjoyed the food provided and that ‘the food is good, no complaints’. The main meal consisted of cheese and potato pie, peas and carrots or chilli and rice. Fresh fruit is now available at all times and fresh vegetables are served each day. The manager discussed the future plan of the redecoration of the dining room, in the meantime new table linen has been purchased. One service user prefers to eat alone, it is arranged that he be served his meals in the dining room before meals are served to the other service users. The acting manager stated that this service user has expressed concerns about the arrangements for Christmas day dinner but was assured that staff will observe his preference for dining alone. Ashleigh House Nursing Home DS0000017177.V270438.R01.S.doc Version 5.0 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 Improvements have been made in supporting service users with their own standards of personal hygiene and healthcare. EVIDENCE: Improvements were noted on the appearance of service users, all were appropriately dressed for the time of year. Staff explained the process and responsibilities of the key worker system in relation to assisting and encouraging good personal hygiene whilst upholding a person’s maximum independence. The care plans record the times and frequencies of healthcare support. Consultant psychiatrist support has been arranged for each service user, reviews have either taken place or have been arranged to take place shortly. Other specialist support is accessed when necessary and includes diabetic monitoring, chiropody, dentist etc. Ashleigh House Nursing Home DS0000017177.V270438.R01.S.doc Version 5.0 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 The home has a satisfactory complaints procedure the effectiveness of which will be determined over time. Progress has been made to procedures for protecting service users from potential financial abuse. EVIDENCE: The complaint procedure has been reviewed; a copy will be displayed in the hall, when the redecoration of the area has been completed. A copy of the complaint procedure has been given to each service user for their information. Documentation for recording all concerns and complaints is available and accessible to staff. An investigation is currently ongoing following an anonymous complaint. The acting manager has a sound knowledge of the Vulnerable Adult Procedures and is planning for all staff to receive training in abuse awareness and whistle blowing shortly. The procedure for dealing and safekeeping of service users personal monies has been revised. Money is held on the behalf of each service user in the locked safe in individually named wallets. A recording sheet documents each transaction made, the service user, acting manager and one member of staff sign at each transaction and check for the accuracy of the recording. The money held in the wallets and the amount on the recording sheet accurately cross-reference. Receipts are kept with the recording sheets. Bankcards and PIN numbers are kept separately in sealed signed envelopes in the wallets. Three service users requested cash at the time of the inspection, the full procedure was observed and appeared satisfactory. Ashleigh House Nursing Home DS0000017177.V270438.R01.S.doc Version 5.0 Page 16 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): 24,26,30 Slight improvements have been made to the homes environment but the lack of attention to detail does not create a pleasing, pleasant or safe place in which to live and work. EVIDENCE: The home is currently undergoing redecoration; a rolling programme identifying each area together with the anticipated time scales has been prepared. Some delays have been experienced due to difficulties with the contractors. The office door was wedged open, the acting manager explained that the door is usually kept shut but is wedged today due to the redecoration of the hall and the wet paint on the doors. It was required that an approved device be fitted to the door to allow the door to remain open but to close efficiently when the fire alarm is activated. During the tour of the premises it was noted that some of the bedrooms had been repainted but not refurbished. Room 13 had been painted pink, the service user had not been consulted as to the colour scheme or any choice of colour offered. The flooring under the floor tiles in the room is cracked and causes a possible health and safety risk of tripping. Of the five bedrooms inspected, four rooms were extremely cold; the radiators were not on. One service user complained that she was cold and had to go to bed in her clothes Ashleigh House Nursing Home DS0000017177.V270438.R01.S.doc Version 5.0 Page 17 to keep warm. The duvets on the beds were very old, thin and tatty, as were the pillows, the duvet covers were old, soiled and ripped. A bedside cabinet was observed in a service users bedroom that was broken and in pieces, other furniture appeared outdated and not up to modern standards. The findings were discussed at length with the acting manager, he informed of the problems with the central heating boilers, and gave an assurance that portable heaters would be available for use until the plumber and heating engineer could be contacted, and new bedding would be purchased. During the inspection four easy chairs were delivered for use in the newly decorated smoke room, it could not be established if they were fire retardant, so were deemed unsuitable for use. The acting manager stated that carpet replacement is planned for all areas of the home following the completion of the redecoration. A cleaning rota has been developed and implemented; this has greatly improved the hygiene and cleanliness of the whole home. Ashleigh House Nursing Home DS0000017177.V270438.R01.S.doc Version 5.0 Page 18 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): 32,33,34,35,36 Improvements have been made to the staffing compliment; however, the staffing levels must be determined by the needs of the individuals’ personal requirements. EVIDENCE: The acting manager acknowledged that the registered nurses have the experience to support the service users, whilst recognising the need for all staff to receive regular training and updates in the core topics and specialist areas. Training in understanding and dealing with violent and aggressive behaviour has been arranged for December 2005. One staff member discussed the opportunity of National Vocational Training Level 2 in care that has been arranged for her and stated that she was really looking forward to the course. The staffing levels have been revised in line with the dependency needs of the service users. The acting manager is now totally supernumery, supported by one registered mental nurse for the 24-hour period, with three care staff during the day and two care staff at night. Catering and domestic staffs are at the home during the mornings. Agency staff are occasionally needed to maintain these levels and to cover for staff sickness and annual leave entitlements. The staffing rota evidenced that these levels are being maintained. Staff meetings are arranged weekly with additional registered nurse meetings held each month. The dates for the meetings are planned well in advance and displayed on the notice board in the office. Ashleigh House Nursing Home DS0000017177.V270438.R01.S.doc Version 5.0 Page 19 The acting manager has introduced regular induction training for all staff, with an allocated time arranged for the sessions. The administrator employed for the group of care homes has reviewed all staff personnel files. These files are now stored securely in the locked filing cabinet together with the staff supervision and appraisal documentation. Ashleigh House Nursing Home DS0000017177.V270438.R01.S.doc Version 5.0 Page 20 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): 37,39,41,42 The recently recruited acting manager has introduced some stability into the home and is supporting and leading both service users and staff through a period of change. The lack of investment to the replacement of essential equipment is not creating a pleasant environment in which to live and work. EVIDENCE: Since the last inspection in June 2005, a new acting manager has been recruited to oversee the day-to-day management of the home. He has considerable experience in working with the current client group and is a first level nurse. The application for the position of registered manager at the home is currently being processed. Service users spoken with stated that the new acting manager is ‘ok’ and that ‘he will listen to you’. Staff stated that he is easily approachable and ‘you know where you are with him’. During the duration of the inspection it was very obvious that a more composed and calm environment has been developed, staff were observed to be attending to their duties and tasks in an Ashleigh House Nursing Home DS0000017177.V270438.R01.S.doc Version 5.0 Page 21 efficient manner, with the service users appearing to be generally more calm and relaxed. The quality assurance and monitoring systems have yet to be introduced. Satisfaction questionnaires were sent to service users in December 2004, the results were not published and no action was taken on the responses to the questionnaire. The registered providers monthly unannounced visit to the home has yet to take place as part of the internal audit programme. The acting manager stated that the policies and procedures relevant to the home would be reviewed and revised as and when necessary. A full independent assessment has been made for legionella and the hot and cold water systems. Numerous problems have been identified in relation to the hot water and central heating system. The acting manager is conducting regular checks to ensure that the hot water temperature is maintained at a safe level and as identified earlier in this report heating engineers are contacted when the heating fails. Ashleigh House Nursing Home DS0000017177.V270438.R01.S.doc Version 5.0 Page 22 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 3 X 3 X Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 1 X 1 X X X 3 LIFESTYLES Standard No Score 11 3 12 X 13 X 14 2 15 X 16 2 17 Standard No 31 32 33 34 35 36 Score X X 2 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ashleigh House Nursing Home Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score 2 X 1 X 3 2 X DS0000017177.V270438.R01.S.doc Version 5.0 Page 23 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 Timescale for action 19/12/05 2 YA6 15(1)(2) 3 YA6 15(1)(2) 4 YA6 15(1) The statement of purpose and service users guide must now be produced in a suitable format and be available for all interested parties. 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 01/01/06 ensure that each service user has a complete, comprehensive and individual plan of care The registered person must 01/01/06 ensure that the service users and/or representatives are fully involved with the care planning process to include the agreement of any identified changes Time scale of 21/06/05 not met. The care plan must detail the 01/01/06 current and anticipated care needs and how these needs will be met. DS0000017177.V270438.R01.S.doc Version 5.0 Ashleigh House Nursing Home Page 24 5 YA14 6 YA14 7 YA16 8 YA23 9 YA24 10 YA24 11 YA26 Time scale of 21/06/05 not met. 16(2)(m)(n) The registered manager must ensure that service users have access to, and choose from a range of suitable and appropriate leisure and therapeutic activities. Time scale of 21/06/05 not met. 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. 13(4)(b)(c) The registered person must 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 not met. 18(1)(a)(c) The registered person must ensure that all staff receive training in abuse awareness and whistle blowing 23(4) 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. 23(2) The registered person must ensure that all furniture for communal use is in good order and meets the required safety standards. Time scale of 31/08/05 not met. 23(2)(b) The registered person must ensure that the floor in room DS0000017177.V270438.R01.S.doc 31/03/06 31/03/06 31/03/06 31/03/06 01/01/06 30/12/05 30/12/05 Ashleigh House Nursing Home Version 5.0 Page 25 13 is repaired 12 YA26 12(2) 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 new bedding is purchased 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 numbers and skill mix of staff are maintained and based on the collective and individual needs of the people living at the home. The registered person must 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 not fully met. The registered person must ensure that the application for a registered manager is forwarded to Commission for Social Care 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 previous inspections. Time scale of 21/06/05 not met. The registered person must DS0000017177.V270438.R01.S.doc 30/12/05 13 14 YA26 YA26 16(2)(c) 16(2)(c) 30/12/05 30/12/05 15 YA33 18(1) 30/12/05 16 YA35 18(1)(c ) (i)(ii) 30/12/05 17 YA37 8(1) 30/12/05 18 YA39 24(1) 12(1) 31/03/06 19 YA39 26 30/12/05 Page 26 Ashleigh House Nursing Home Version 5.0 make monthly unannounced visits to the home, prepare a written report. A copy of which must be available to the manager and Commission for Social Care Inspection 20 YA42 23(2)(p) 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. 30/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ashleigh House Nursing Home DS0000017177.V270438.R01.S.doc Version 5.0 Page 27 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.V270438.R01.S.doc Version 5.0 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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