Inspection on 13/10/08 for Ashleigh Manor

This inspection was carried out on 13th October 2008.

CSCI found this care home to be providing an Poor service.

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

Other inspections for this house

Ashleigh Manor 05/10/09

Ashleigh Manor 08/04/09

Ashleigh Manor 20/11/07

Ashleigh Manor 19/04/07

Ashleigh Manor 19/05/06

Ashleigh Manor 19/10/05

Ashleigh Manor 10/06/05

Ashleigh Manor 15/12/04

Ashleigh Manor 18/06/04

Ashleigh Manor 03/02/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Extracts from inspection reports are licensed from CQC, this page was updated on 31/03/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Ashleigh Manor 1 & 3 Vicarage Road Plympton Plymouth Devon PL7 4JU     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Kim Fowler     Date: 1 7 1 0 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 31 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 31 Information about the care home Name of care home: Address: Ashleigh Manor 1 & 3 Vicarage Road Plympton Plymouth Devon PL7 4JU 01752346662 01752336233 loretta_severn@hotmail.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Maureen Lawley Type of registration: Number of places registered: Mrs Maureen Lawley,Miss Loretta Maher-Lawley care home 38 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: Five residents Category PD 50yrs Date of last inspection Brief description of the care home Ashleigh Manor is a care home providing personal care and accommodation for thirtyeight people, over the age of 65, who may have dementia and/or physical disabilities. Five of the thirty-eight may be admitted under the age of 50. The home does not provide intermediate care but does accept a small number of service users who require short-term respite care. Any nursing care is provided through the community nursing service. Mrs Maureen Lawley and Ms Loretta Maher-Lawley currently own the home. The Registered Manager is Mrs Maureen Lawley. The home, opened in 1989. The home Care Homes for Older People Page 4 of 31 38 0 38 Over 65 0 38 0 Brief description of the care home is a large detached house set within its own grounds in the residential area of Plympton. It is close to local shops and amenities and public transport is easily available. The majority of rooms are single and are on the ground and 1st floors. All the bedrooms contain wash hand basins, twenty-six have en suite toilets, seven have en suite showers and one has an en suite bath. In addition to the en suite facilities the home has five bathrooms, four of which are assisted, and four toilets. The home naturally separates into two units linked at the rear of the building by a large conservatory and covered walkway. On the ground floor there are four dining rooms and four lounge rooms. Other areas, such as hallways, have comfortable chairs and tables. The home has access for wheelchair users including a passenger lift and stair lifts and ramps to the garden. There is parking space available at the front of the home, as well as on street parking nearby. The home has a large garden to the rear of the property. Current fees range from #333 and #406. Additional charges are made for: hairdressing, Chiropody, Reflexology, outings and toiletries from the home?s shop. The last inspection report can be obtained from the home on request. Care Homes for Older People Page 5 of 31 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. The inspection was unannounced and took place over two days. The first day started on the 13th October at 10am and finished at 3:40pm. The second visit was carried out on 17th October at 10:00am and finished at 1:30pm. Miss Loretta Maher-Lawley one of the Registered Providers was available throughout both days and the Manager of the home was also available to assist. The inspector made a tour of the building and spoke to most the people living at the home and the staff on duty at the time of the inspection. Documentation relating to the Care Homes for Older People Page 6 of 31 care planning process and the management of the home were examined. Surveys were sent to people living in the home and staff working in the home. Four surveys were returned form people living in the home and 2 staff surveys were also returned. Any comments received are in the relevant section of the report. The home is currently undergoing a major extension within the rear of the property. This building work is part of the new extension that is currently being built to extend the number of beds from 38 to 66. People spoken to during the inspection did not seem affected by the ongoing work. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 8 of 31 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 9 of 31 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who are considering admission to the home can be confident that a full assessment will be completed before admission to ensure the home can meet their individual needs. Evidence: All files examined contained a pre-admission assessment. Also in place were the placing authoritys detailed care plans. The Manager or her deputy will visit any prospective new admission to gather information to completed the pre-admission assessments. Some people living at the home were spoken with about their admission. Several were able to confirm that they had received information prior to moving in and another said, My daughter visited the home before I moved in as I was unable to. The homes AQAA states, All prospective clients are invited to come for the day, have a meal, Care Homes for Older People Page 10 of 31 Evidence: meet other clients and staff or just come for afternoon tea/coffee. Ashleigh Manor does not offer intermediate care. Care Homes for Older People Page 11 of 31 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff and manager provide good personal support to people who live at the home. Ensuring the promotion of privacy and dignity at all times. The homes poor practices relating to medication administration place people living at the home at risk. Evidence: Each file examined of people living at the home contained an individual care plan based on care needs and how the home would meet these needs. The daily care plans are easy assessable for staff on duty and risk assessments are held on individual files for the protection of all people living at the home. These care plans give detailed instructions to all staff as well as information to new staff to ensure intimate personal care is being provided in a manner that meets with the approval of people receiving the care. This is particularly important where people Care Homes for Older People Page 12 of 31 Evidence: are unable to express themselves verbally. Each Care plan in place is supported by an A&E Admission form, these forms are to accompany people on admission to hospital to ensure all important information is past onto the hospital in case of emergencies. However several of these forms examined were not completed in full. Each new admission has a Bruise Chart completed; these charts record any unexplained bruise and marks. One chart completed for a new admission contained a high level of unexplained marks and bruises. The home did not follow this up by reporting this to the alerter team for a safeguarding referral nor did they refer to the GP or hospital. There were also inconsistency in the recording of bruises and marks into daily records and not reporting this severe bruising to the management of the home or to the Accident and Emergency department when this person was admitted. Evidence was recorded into individual files that people living at the home are referred to the District Nurse team when needed. People currently receiving treatment from the District Nurse team have an individual designated file held in their individual bedrooms. All people living at the home have access to all health care services and this information was recorded into individual files examined. These files recorded that there was input from other professionals including GPs, Macmillan Nurses, chiropodist and consultants based at the local hospital. The home uses the blister pack system to dispense medication. A new system is currently being introduced and will commence in a few weeks. From discussion with the staff that dispenses the medication they have received recent and regular medication training. However some errors in the administration, recording and storage of medication in particular the controlled drugs places people receiving medication at risk. The Medication Record Sheets examined showed that some had been signed for in pencil or tippexed out, some medication had not been signed for and medication held outside of the blister pack system did not tally when checked with amount received from the pharmacist and the amount that should have been dispensed. The home had received some controlled drug for a new admission and these had not been recorded into the controlled drug registered as required. This new admission to the home came with other medication, including another Care Homes for Older People Page 13 of 31 Evidence: controlled drug; this was recorded into the controlled drug register. However the dose recorded on one bottle contradicted what was recorded onto the discharge sheet received by the home and the second bottle of medication received. The home called the previous home to check medication but did not confirm the correct dose for this medication until 4 days after admission with the GP surgery who prescribed the medication. The homes AQAA records under a heading of medication, Regular monthly audits on stock, regular audit on MAR Sheets and discussion with staff who handle medication. The inspector spoke to most people living at the home and some were able to comment directly about their experiences of living at the home. All clearly stated that they were well cared for. The inspector observed those residents with confusion being treated respectfully by the care staff, staff knocking on bedroom doors and staff assisting people with meals. Several people said they were assisted promptly. It was observed that people who chose to wander freely through the home were able to. One person said, The staff are lovely and a survey returned said, Our medical support has been wonderful. Care Homes for Older People Page 14 of 31 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people living at Ashleigh Manor can be confident that the home offers good home cooked meals. The home welcomes and encourages families and friends to visit and regular activities and trips out are arranged. Evidence: People were observed moving freely around the home. Some people remained in their individual bedrooms and one couple said, We like to stay here in our room. Staff were seen interacting with people and discussing everyday topics and included assisting individuals when needed showing staff were aware of the needs of people living in the home. Observation showed a staff member assisting people living in the home with craft and other activities during the first day of the inspection. Advertised on the homes notice board were planned activities and trips out. This included a Theater Pantomime trip Care Homes for Older People Page 15 of 31 Evidence: and a Halloween party. All family visits and contact is recorded into individual files and daily records examined showed recent family visits for several people living in the home. One relative was spoken to on the second day of the inspection and confirmed that they were able to visit the home at any reasonable time and were always made to feel welcome. All bedrooms visited contained personal possessions and items and several people living at the home said that the home encouraged them to bring in items from home. A local Advocacy service details were held on individual files and the home will apply for advocacy input when needed. All people who were able to made positive comments about the food provided. One of the cooks was spoken with during the inspection about the menus and food on offer. The homes 4 weekly menus was displayed for all to see and showed a varied and nutritional diet. It was evident from the food seen served at lunch time, Chicken casserole or cheese omelettes, potatoes and fresh vegetables followed by home made fruit crumble and custard, that the food was home cooked using fresh products. The meal was well presented and freshly prepared and staff were observed assisting people were needed. The homes AQAA states, Homes cook encouraged to interact with clients, discuss meals/menus. The comments received from people living at the home about the food provided included, Lovely food and too much of it! One person said of the lunch being served, It was very nice. One survey returned said, The cook helps with the diet. Care Homes for Older People Page 16 of 31 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who live at Ashleigh Manor and their relatives can be confident that any issues of concern or complaints would be taken seriously and dealt with promptly. Robust procedures in place responding to suspicion or evidence of abuse or neglect would ensure the safety and protection of people using the service. Evidence: The home has a complaints procedure displayed on the homes notice board and recorded into the Service Users Guide and Statement of Purpose. The home has not received any formal complaints and the Commission has received none. The homes manager and her deputy are available most days and will discuss any issues raised by people living in the home or visiting family members straight away to resolve any issues. Some of the people living at the home were able to confirm that the homes manager and her deputy are approachable and could discuss any concerns. One person said, They always comes in to see us and check everything is OK. Some of the staff spoken with confirmed that they had completed a safeguarding course, provided by a local trainer. Another course by this trainer is arranged for early Care Homes for Older People Page 17 of 31 Evidence: next year to ensure all staff has received this training. A discussion with some staff showed that they understood the process of adult protection. However as previously mention under Health and Personal Care section, a completed bruise chart held for one person admitted to the home was not followed up by alerting the Safeguarding Team to unexplained bruising and marks. The homes AQAA returned to the Commission does not refer to any information on what the home would do if they became aware of a Safeguarding issue, nor does it make any reference to any improvements the home plan to make to the homes Protection Polices and Procedures. Care Homes for Older People Page 18 of 31 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Poor hygiene and cleaning practices place people living in the home at risk from infection. Some areas of the home are pleasant and homely however some areas were not maintained and could provide a risk for people living in the home. Evidence: A tour of the home was carried out and several issues of concern were noted and relayed to one of the Registered Provider, Miss Loretta Maher-Lawley on the second day of the inspection. The home has a room opposite the main kitchen that the staff use to make hot drinks and store drinking provisions including coffee and tea. This room contained a large hot water urn, kept hot at all time, and it was observed that the door was held open with a drinks trolley. This room also held chemicals that were not locked away. Therefore placing people who live at the home at risk of scolds and easy access to dangerous chemicals. The main kitchen was inspected and found to be very unclean and dirty. This included the edge of the flooring around the kitchen to be loose and food particles gathered Care Homes for Older People Page 19 of 31 Evidence: there. Several fridges were held in the kitchen and each was examined. One contained opened pots of food and not labeled to state how long each item had been opened, each side of the free standing fridge/freezer contained particles of food where they had not been cleaned for some time, the smaller fridges on examination inside were very dirty and unclean in particular the fridge that held defrosting meat. Many of the fronts of the cupboards and drawers in the kitchen had food and liquids spillages down, as did the two hatches were food is pasted to the staff to serve people living in the home. The main extractor fan in the kitchen was covered in dust showing that it had not been cleaned for some time. The inside of the oven and microwave oven were checked and had food spillages and particles of food in each showed these had not been cleaned for sometime. Miss Loretta Maher-Lawley agreed to have the kitchen closed for a day and deep cleaned. The homes laundry rooms were inspected and chemicals were found not to be secured in this room were people living in the home could gain access. The door to one laundry room was held open with a wooden wedge and from discussion with some staff members they confirmed that this room was not locked at night again with possible access to people living in the home. It was pointed out that the exit point from this room had a deep step down into the corridor and a large breeze block brick had been placed onto the floor. This breeze block brick was unsecured and loose placing people who access the laundry area at risk from trips and falls. Another food storage area in the basement was examined and found to be unclean and dirty with food particles and dust on the floor. The tour of the rest of the home was made and several rooms were noted to have a slight odour. The hallway carpet on the first floor was stained and ruffled, however the registered provider confirmed that this carpet was being replaced the following week and one room with an odour was having vinyl flooring fitted. The carpet in one of the lounge areas on the ground floor was found to have frayed edges and could place people living in the home at risk of trips. The homes AQAA states under, what the home do well, Preserve safety of clients. The rear of the home is having a large extension fitted. This will include a new 28bedded unit when it has been completed and Registered with the Commission. Several staff commented that the work had taken longer than expected but it did not generally affect their work. People living at the home spoken to do not find the building work a Care Homes for Older People Page 20 of 31 Evidence: problem with one new admission stating, I will move into one of the new bedrooms when it has finished. A tour of this unfinished extension was undertaken and the Registered Provider, Miss Loretta Maher-Lawley, was advised to contact the Commissions Regional Registration Team on completion of this extension to apply for registration. Several people living in the home commented that there rooms were regularly cleaned and the cleaners would visit daily. Appropriate disability equipment is provided in the home, and these include a passenger lift, hoists, wheelchairs, and a call bell system. This equipment provides the people living at the home with a building that is appropriately adapted to meet their needs. Risk assessments are in place and are reviewed annually or as necessary if anything changes. Peoples rooms contained personal items including furniture, ornaments and pictures that reflect their personality and interests. People were seen moving about the home, some with the assistance of staff. The process for the removal of clinical waste was discussed and was satisfactory dealt with and one staff member confirmed they had completed infection control training. Other staff confirmed that the home provided disposable aprons and gloves for their protection. And the manager confirmed that most staff had completed infection control training. Care Homes for Older People Page 21 of 31 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home are supported by well-motivated and caring staff in sufficient numbers to meet the needs of those currently living at the home. Evidence: On day one of the inspection there were 35 people living in the home and 6 care staff supported these people with cleaners, laundry assistance, handyman and administration staff also on duty. The homes manager of care and one or the registered providers were also available. The duty rota was examined and it shows sufficient numbers of staff for the amount of people living in the home and their dependency. The staff interviewed felt that the home had sufficient staff on duty and observation of staff throughout the inspection showed them to be relaxed, patient and helpful when assisting the people. Some of the people living at the home were able to state that the care received is very good. Currently 15 of the 22 care staff holds an NVQ qualification at level 2 or above this is a nationally recognised care qualification for which staff have had their work Care Homes for Older People Page 22 of 31 Evidence: performance and knowledge evaluated by an external training organisation. Through this training staff received further training in first aid and health and safety ensuring they have the knowledge to deal with emergencies. The home has 5 staff currently undertaking NVQ training. Examination of staff files showed that all staff had the required pre-employment checks, including CRB, Criminal Record Bureau Disclosure, in place ensuring as far as possible unsuitable staff are not employed. Staff confirmed that the home holds staff meetings and these staff interviewed felt that they were able to express their view at these meetings. Regular consultation with staff ensures staff can contribute to the running of the home and are aware of the homes aims and objectives, philosophies of care and promotes consistency and improvement. Some staff spoken with confirmed that they held a NVQ certificate and other are hoping to start this qualification soon. The designated staff training file held training certificates that confirmed that a variety of training is undertaken by staff, including fire safety, protection of vulnerable adults and moving and handling. The manager said that an outside training company provides much of the training. Currently the medication training is completed via a correspondence course for all staff. A new system of administration of medication is to be introduced in the near further and the medication training will then be carried out by a Pharmaceutical company. The homes AQAA states, Continue to build on our in house training programme. The home is to introduce a new Induction for staff and the manager believes this will meet the National Training Organisation specification. One survey returned said, Im very happy the support the staff give me and one said, Very good staff and another said Need more staff. A staff survey returned said, No time to sit with service users, talk to them, give them personal attention and went onto say need more staff. Care Homes for Older People Page 23 of 31 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff actively seeks the views of people living in the home so that they can find ways of ensuring continual improvement of the service the manager has the respect of people living and working in the home. Not all areas of the home are safe, clean and secure placing people at risk. Evidence: Miss Loretta Maher-Lawley, one of two Registered providers and the homes care manager, Carol Mills, are in the home most days. The other Registered Provider is also the Registered Manager and is currently unavailable. The homes care manager has a Registered Managers award as well as a NVQ in Care. This manager is not Registered with the Commission. A discussion was held with the manager on quality assurance. The manager confirmed that these had been completed within the last year. The results are currently being Care Homes for Older People Page 24 of 31 Evidence: looked at and the feedback will be given to relatives and people living in the home at a Relative/Family/Resident meeting arranged for the following week. The manager said she would continue to do quality assurance audits like this on a regular basis so that ongoing improvement can be measured. All the people living in the home have a lockable safe in their bedrooms. The home only holds money for one person and the records held did not have a clear audit trail to show expenditure, income and whom the money was given to. Some staff spoken were able to say that had received supervision session but records examined dated 7months previously. The manager of care stated that she does carry out supervision but it is not always recorded. Sampling of servicing records indicated that equipment is serviced regularly and maintained in good working order, including the fire alarm system. Certificates were available on all Health and Safety equipment. Gas and electrical appliances were being routinely serviced and checked. The new Gas service certificate was not available for inspection however the owner confirmed that this had been carried out within the last week and the home were waiting for a updated certificate. The fire protection system was well maintained. Maintenance checks are being carried out. The staff member is receiving appropriate fire protection training to ensure that they have the skills to deal with emergencies. As previously mention under Standard 26, areas of the home do not met the required stand of hygiene as required. The homes AQAA does not record any information or improvements under the Health, Safety and welfare of service users and staff to promote and protect the home. Good health and safety practices reduce any unreasonable risk, affecting people living at the home, to an acceptable level. Care Homes for Older People Page 25 of 31 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action 1 7 15 All care plans must be 31/01/2008 completed to ensure the staff are able to meet the needs of people living at the home in respect of their health and welfare. The home must be kept 31/01/2008 thoroughly clean and odour free, so that the environment is pleasant and hygienically safe for residents. All radiators and hot water pipes must be guarded or have low surface temperatures to prevent the risk from contact burns. All procedure of infection control must be adhered to protection people from infection. 31/01/2008 2 19 23 (2)(d) 3 25 13(3) 4 26 13 (4c) 31/01/2008 5 38 37 The Registered person must 31/01/2008 notify the Commission of any incident of absences by a service user and any event in the care home which adversely affects the well being or safety of any service user. This will ensure the Commission is aware of all Care Homes for Older People Page 26 of 31 events affecting service users in the care home. 6 38 13(3) People living at the home 31/01/2008 must not be exposed to unnecessary health and safety risks therefore: - Fire doors must be closed and hot equipment must not be left unattended and pose a risk in the event of fire. -Carpets and lino must be secure and safe and not pose a trip hazard. Care Homes for Older People Page 27 of 31 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 13 All care plans must be completed in full. This includes all forms held on individual files and followed up with appropriate agency when needed. This will ensure that staff are able to meet the needs of people living at the home. 31/12/2008 2 9 13 All medication, in particular controlled drugs should be recorded, audited and any errors or changes reported to the GP and recorded onto individual files. This would ensure that all service users receive the correct medication. 31/12/2008 3 18 13 Any suspicion of abuse or 31/12/2008 neglect must be reported to Local Safeguarding teams or Health care professionals. Care Homes for Older People Page 28 of 31 This would ensure all people living in the home were protected from abuse or neglect. 4 19 23 The home must be well 31/12/2008 maintained and made safe for people living in the home therefore: all rooms holding equipment that can scald must be kept locked. All chemicals must be locked away. Any loose or temporary steps must be made safe and secure. This will protect the health and safety of all that live in the home. 5 26 16 The home must be kept 31/12/2008 thoroughly clean and odour free therefore, The kitchen must be kept clean and free from food particles. Any food storage areas must be clean and tidy. This would ensure that all the people living in the home live in a pleasant and is hygienically safe for all. 6 38 13 People living at the home must not be exposed to unnecessary health and safety risks therefore, Fire doors must be closed and hot equipment must not be left unattended and pose a risk in the event of scalds and fires. Carpets must be made secure and safe and not pose a trip hazard. 31/12/2008 Care Homes for Older People Page 29 of 31 A safe environment will protect all that live in the home. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 2 35 36 All money held by the home for individuals should have a clear audit trail to show income and expenditure. Staff supervision should be regular and recorded. Care Homes for Older People Page 30 of 31 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 31 of 31 - 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!