Inspection on 19/04/07 for Ashleigh Manor

This inspection was carried out on 19th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ashleigh Manor 05/10/09

Ashleigh Manor 08/04/09

Ashleigh Manor 13/10/08

Ashleigh Manor 20/11/07

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Ashleigh Manor 1 & 3 Vicarage Road Plympton Plymouth Devon PL7 4JU Lead Inspector Anita Sutcliffe Unannounced Inspection 19th April 2007 09:00 X10015.doc Version 1.40 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 Manor DS0000003570.V330772.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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 Manor DS0000003570.V330772.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashleigh Manor Address 1 & 3 Vicarage Road Plympton Plymouth Devon PL7 4JU 01752 346662 01752 336233 loretta_severn@hotmail.com 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) Mrs Maureen Lawley Miss Loretta Maher-Lawley Mrs Maureen Lawley Care Home 38 Category(ies) of Dementia (38), Old age, not falling within any registration, with number other category (38), Physical disability (38) of places Ashleigh Manor DS0000003570.V330772.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Five residents Category PD 50yrs Date of last inspection 19th May 2006 Brief Description of the Service: Ashleigh Manor is a care home providing personal care and accommodation for thirty-eight 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, is currently undergoing a change of ownership, but remaining within the family. The 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 £303 and £386. 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. Ashleigh Manor DS0000003570.V330772.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was to check the home’s compliance with the National Minimum Standards for Older People. Prior to the inspection the home provided current information on the service. The Commission anonymously sought opinion from the people (known as residents) living at the home, staff and health and social care professionals in regular contact with the home. Time was spent talking to residents individually, and two hours was spent observing the experience of residents in a lounge. The care of two residents was examined in detail. This involved reading their care records, meeting them, visiting their room and discussion with staff. Care and medication records were examined. Both registered providers were involved in the inspection, although the person designated to manage the day to day running of the home provided most information on their behalf. What the service does well: Residents, their family and staff are full of praise for the home. Comments include: • “I find the home really very good. The staff are caring, compassionate and I feel they cater very well for individual needs. I have to say that they are also very thoughtful towards the relatives keeping us informed and are welcoming when we visit.” “They do a great job!” “The residents are treated with kindness and respect to preserve their dignity and respect. They are treated as individuals”. “We give the residents a lovely homely feeling”. “The managers really care and are very much valued by the residents and committed to their care. This supports the care staff”. • • • Ashleigh Manor is a friendly and relaxed family run home providing empathy and individual care. The professional and structured approach taken by staff ensures needs are understood and met. It is run with the wellbeing of residents at heart. Staff feel supported and well trained. The standard of care planning is high ensuring staff are fully aware of a resident’s needs. Residents’ rights are promoted; family are kept informed and feel welcome. The quality of the service provided is well monitored with all stakeholders in the home having the opportunity to offer opinion. Much of the home environment is pleasant providing variety and space. Ashleigh Manor DS0000003570.V330772.R02.S.doc Version 5.2 Page 6 The laundry is well equipped with commercial washing and drying machines. What has improved since the last inspection? What they could do better: Confused residents are not fully safeguarded, sometimes through staff practice, sometimes as a result of the environment. Concerns identified were: • • • • Cleaning chemicals found in a corridor and resident’s bedroom, which pose a risk if touched or swallowed. Commodes, which had not been cleaned and were smeared with toilet waste. Freestanding wardrobes, not secure and posing a risk from being pulled over. A light switch, attached to the side of a free standing wardrobe, with the connecting wire between the wardrobe and the wall. With the risk of movement this could lead to exposed wiring. This is an electrocution hazard and contrary to wiring regulations. A door on an emergency relaese system was propped open and therefore could not close in the event of a fire. Two carpets were uneven, posing a trip hazard. Tooth paste stored with an ointment prescribed for external application, dangerous if confused and used in error. Unguarded radiators and the risk of contact burns. • • • • Health and safety is difficult through the current lay out of the home; laundry has to pass by the kitchen and food storage area and there is insufficient room for secure medicine storage. Residents would also benefit from environmental adaptations, which help people orientate themselves in the building. Residents’ sitting space should not be bombarded with different noises, which affect concentration. This would improve the opportunity for them to talk to others and be involved in activities. Activity and food/menu options need to be reviewed and expanded to better meet residents’ expectations. Residents should not have the indignity of continence covers on their chair when not needed. Storage, safe handling and record keeping of medication should be reviewed and improved, as it is not fully safe. Recruitment of new staff needs to be more robust, to ensure all newly employed staff are safe to work with vulnerable adults. Ashleigh Manor DS0000003570.V330772.R02.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ashleigh Manor DS0000003570.V330772.R02.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR 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) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashleigh Manor DS0000003570.V330772.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 4 (Standard 6 does not apply to Ashleigh manor). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A thorough assessment prior to admission ensures staff are fully aware of the resident’s needs and wishes. Residents with dementia receive support, kindness and empathy but their lives could be further improved through a more broad understanding of their needs. EVIDENCE: A recently admitted resident discussed his admission to the home. What he said was consistent with his assessment record, and included his physical health, emotional, social and psychological needs. The resident said the admission was arranged with the help of his family and he was satisfied with how it had been done. Discussion with a senior member of staff confirmed his individual needs were understood; he was clearly relaxed and confident in her presence. Where the resident had made a specific request this had been Ashleigh Manor DS0000003570.V330772.R02.S.doc Version 5.2 Page 10 honoured. Going out alone had been identified as a risk, and the resident understood and agreed with the decision for him not to do so. Most staff contact with confused residents was sensitive and respectful. It is a homely and emotionally safe environment. The design of the building offers good opportunity for those who wish to wander and this will be further improved when the garden is safe and accessible. There has been limited environmental adaptation to help confused residents find their way around. The providers say this will be fully considered within forthcoming plans. A newly employed member of staff understood effective methods of communication with residents who have dementia. However, this was not through induction training as it is not included. Staff with no previous care history would have less insight. Some staff have received training in dementia care, and the registered manager says all will have done by December 2007. The experience of residents with dementia, who spent much of the day in one lounge, could be far improved through an understanding of how the environment can have a positive or negative effect. In this case, constant background noise from an unwatched television, traffic, radio and general chatter. (See Standard 12). Ashleigh Manor DS0000003570.V330772.R02.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ health and personal care needs are well met by conscientious and knowledgeable staff. Residents are respected, but some routine practice at the home is demeaning. The system used for the recording and storage of medicine to be administered to the residents had the potential to place the residents at risk. EVIDENCE: The majority of residents surveyed said they got the medical support they needed; others said they usually do. Two thirds said they received the care and support they need; one third said they usually do. Care is well planned and regularly reviewed. The resident, or family when necessary, are involved in the planning and kept informed. Staff use the care plans to inform them of how care should be delivered. Records show that all Ashleigh Manor DS0000003570.V330772.R02.S.doc Version 5.2 Page 12 aspects of health care are well managed. Staff commitment to a high standard of health care is commendable with close monitoring, specialist training to prevent health care problems and liaison with specialist health care professionals in the community and hospitals. A staff member said: “Residents are treated with kindness and respect to preserve their dignity and respect”. Other comments, and most observation, supported this. However, seat covers, which protect seating where a resident might be incontinent, are used regardless of need. One was found in an unoccupied room (assuming the next occupant would need it) and another in the room of a fully continent resident. Residents have the opportunity to handle their own medication if they wish and any risk associated is assessed and managed. The home approaches the handling of medicines in a professional way; they are trained and policies and procedures are in place. However, some practices add risk. Some medicines are stored in a room, which has the duel use as a hairdressing and chiropody room. Medicine storage within the room was not at all robust and, although locked, could have easily been forced open. Some creams and ointments were in use by residents to whom they were not prescribed and in one room a tube of ointment was kept in the same container as toothpaste; dangerous if confusion occurred between the two. Medicine records were clear. However, not all medicines had been counted and recorded into the home so a full audit was not possible. Where information was hand written it was checked and recorded by one staff and not two, as recommended for additional safety. Ashleigh Manor DS0000003570.V330772.R02.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are enabled to be individual and make choices about their lifestyle, but for some activities of interest to them are limited. The menu does not meet the expectations of some residents. EVIDENCE: Five residents said there were always activities they could take part in, three said there usually were and three said sometimes. The manager said that there aren’t as many quizzes and games as there used to be. However, residents have the opportunity to request activities and staff try to meet those requests. Some staff and residents’ relatives felt more staff are needed to provide one to one attention/activities. (See Standard 27). Some residents were observed reading newspapers, interacting with staff and walking around the building. Some were less engaged with the world around them spending the time watching or sleeping. Relatives felt positive about the Ashleigh Manor DS0000003570.V330772.R02.S.doc Version 5.2 Page 14 home saying: “The home allows those who are able to live life in a active way with help”, and “Staff cater very well for individual needs”. The variety of space available lends itself well to different activities. However, some immobile residents with dementia spent the majority of their day time in a lounge with a television on, even during an organised activity. There was also traffic sound, general chatter and house ‘noise’. At one point a radio could also be heard. This deluge of background sound made any concentration difficult. In a two-hour period the television was looked at briefly and by only one resident with most spending the time with their eyes closed unless staff engaged with them. Relatives and staff spoke about the friendliness of the home one staff member saying: “The residents are treated with kindness and respect to preserve their dignity and respect. They are treated as individuals. A relative said: “They understand my mother’s needs and her dislike of being in large groups and always manage to achieve a balance whereby she is able to participate in activities when she wants but not when she does not want”. Relatives confirmed that they are kept informed and felt welcomed at the home and we observed expressions of affection and fun between staff and residents. Residents spiritual needs are met by visiting clergy from local churches. Plans of care provide information about likes and dislikes, needs and desires and there was good evidence, from observation and discussion, that individuality is promoted at the home. Only four residents surveyed said they always like the food, five said ‘usually’ and two said ‘sometimes’. There was equally mixed response when this was discussed during the visits. The menu, although balanced nutritionally and with some resident involvement in choice, was generally unexciting. The main meal is set, with an alternative if requested. Many residents would be unable to make those requests, but staff say they know likes and dislikes. Residents said the quantity of food is good. Staff monitor the diet of residents very well and make every effort to provide food at the time and place it is wanted. Ashleigh Manor DS0000003570.V330772.R02.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from staff commitment to their well-being and the way complaints would be managed. Residents are protected from abuse and their legal rights are protected. EVIDENCE: The ten residents responding to surveys said they knew how to make a complaint and most said they knew who to speak with if they had a concern. A newly admitted resident was clearly comfortable in the presence of a senior member of staff, who says she sees most residents each day and is open to discussing any concerns they may have. The home has received no complaints and the Commission have received no complaints about the home. Staff, both care and domestic, receive training in how to protect vulnerable adults from abuse. Several times advice has been sought when residents have used behaviour, which posed a risk to themselves and/or others. Observation of resident/staff interaction indicates that staff understand how to manage challenging situations though one member of staff said they would like additional training in this. Ashleigh Manor DS0000003570.V330772.R02.S.doc Version 5.2 Page 16 The home asks residents if they wish to exercise their right to vote, and their decision is recorded. Whenever possible, with risk considered and managed, the resident is able to take the lead in how they will live their life, their rights as individuals respected. Ashleigh Manor DS0000003570.V330772.R02.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 & 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The pleasant and homely environment is not maintained to a safe standard. The inconsistent standard of hygiene puts residents at risk from infection. EVIDENCE: Individual rooms and all communal parts of the home were visited. The rambling lay out of the building provides much variety and plenty of space to walk. The good access to a patio area ensures residents are able to go outside, and some were seen doing so. However, the rest of the garden is currently untended, and as such not safe for use, but can be viewed through the large windows, which provide far-reaching views. Ashleigh Manor DS0000003570.V330772.R02.S.doc Version 5.2 Page 18 Some bedrooms are very personalised, containing residents’ own furniture and fittings. A newly admitted resident said she was very pleased with her room, which was light, warm, fresh and, she said, comfortable. However, several health and safety concerns were identified in other rooms. They were: • A lack of radiator covers which present a risk from contact burns. • A light switch attached to the side of a free standing wardrobe, with the connecting wire between the wardrobe and the wall. If the wardrobe moves it could lead to exposed wiring. This is also contrary to wiring regulations. • Freestanding wardrobes, not very ‘solid’, which could fairly easily be pulled over. • A bedroom door, on the home’s automatic fire safety release system, propped open with a foot rest, posing a risk in the event of fire. • Worn, ridged carpet, posing a trip hazard. The provider is aware that the home environment needs to be updated and improved; safety must be given immediate priority. Some consideration has been given to meeting the specific needs of residents with dementia. Rooms have name signs and one was seen with a photograph of the person; this helps orientation. However, environmental adaptation could be further improved. Some good practice guidelines were discussed. (See also Standard 4). Infection problems, highlighted as a problem within the Plymouth area, and posing a problem at Ashleigh Manor, have occurred. The home has taken and acted on professional advice. Improvements have been made to the laundry equipment, which is of a standard appropriate to the needs of the home. Staff use protective clothing and receive infection control training. The majority of the home was fresh. More than half resident survey responses said the home was always fresh and clean, just less than half said it usually was. The home appeared generally clean, although some areas, including the laundry and two bedrooms, needed dusting and a member of staff said some carpets were dirty. However, commodes checked were soiled, some badly. This is both unpleasant, poses an unacceptable hygiene risk, and undermines the other good hygiene practices in place. In addition, the laundry and kitchen are in close proximity and the laundry surfaces not sufficiently cleanable. Current plans to improve the layout of the home will, the registered provider said, reduce risks from cross infection. Ashleigh Manor DS0000003570.V330772.R02.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ needs are met through the skill, knowledge and commitment of staff. Recruitment practice does not fully protect residents from staff unsuitable to work with them. EVIDENCE: Most residents’ surveyed said that staff are always available when needed. Staff say they have enough time to complete tasks but two requested more time to spend with residents: “I’d like time to sit with residents and communicate with them”. Two of the three relatives survey replies state that more staff would be a benefit, saying staff “always seem very busy”. The manager said staff numbers are kept under review and the staffing arrangements allow for a hand over of staff information and additional staff at busy times of the day. All staff surveyed said they felt supported in their work and were never asked to care for residents outside their area of expertise; that they know what they are doing. For the most part this was observed as so. Half of staffs interaction with residents was good, most other satisfactory. Staff assistance to move Ashleigh Manor DS0000003570.V330772.R02.S.doc Version 5.2 Page 20 residents, sometimes involving the use of equipment, showed that they understood correct procedure and were sensitive to the feelings of the resident. Senior staff have good knowledge of residents’ needs and were available to supervise newer staff. A recently employed care worker said she was impressed by the training and support she had received at the home. There is a continual programme of training to ensure staff knowledge and competence. This has included: first aid, mouth care, food hygiene, medication, pressure relief and protection of vulnerable adults. Half of the current care staff have achieved the National Vocational Qualification (NVQ) in care, which is an indicator of their competence. Training also includes dementia care. Although current practice in this is generally good it could be further improved. (See Standard 4). Staff surveys indicate that the home’s recruitment practice does not ensure residents are protected from people unsuitable to work with vulnerable adults. The manager says there have been several staff recently employed and she was unused to the process. A newly employed care worker confirmed that she had started employment without all necessary safety checks being completed, but said she had been fully supervised at all times. Ashleigh Manor DS0000003570.V330772.R02.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ independence and well-being are promoted by a management committed to their best interests, but they are not safeguarded from hazards within the home environment. EVIDENCE: Work in the home is delegated to a structured and well organised team of senior staff with qualifications in care and management. Comments from staff include: “The managers really care and are very much valued by the residents and committed to their care. This supports the care staff”. Residents were clearly relaxed in their company and looked well cared for. Ashleigh Manor DS0000003570.V330772.R02.S.doc Version 5.2 Page 22 Several methods are used at the home to ensure the quality of the service is monitored. These include surveys, resident and staff meetings; there is also a relatives association which provides information and ideas. Staff are allocated specific tasks so as to ensure the smooth running of the home. These include maintenance, servicing and stock control. The manager monitors events such as accidents so that no incident is seen in isolation as preventative actions may be necessary. The standard of formal quality monitoring is good. However, the manager has yet to produce an internal annual audit so that quality assurance is a year on year progression towards continual improvement. The home does not keep money or valables on behalf of residents, who each have a lockable cupboard in their rooms for the purpose. The manager said the home has no involvement in residents’ financial arrangements. Some serious health and safety concerns were identified. These were: • Freestanding wardrobes, not secure and posing a risk from being pulled over. • A light switch, attached to the side of a free standing wardrobe, with the connecting wire between the wardrobe and the wall. With the risk of movement this could lead to exposed wiring. This is an electrocution hazard and contrary to wiring regulations. • A door on an emergency relaese system was propped open and therefore could not close in the event of a fire. • Two carpets were uneven, posing a trip hazard. • Tooth paste kept in the same container as an ointment for external application. • Cleaning chemicals left unattended where confused residents had access to them. • Inadequately cleaned commodes, posing an infection risk. The home was required to make some immediate changes to ensure the safety of residents. Generally the servicing of equipment was within required timescales. Some hazards are being removed, an example being the covering of radiators which pose a risk from contact burns. Plans to change the home environment will also provide the opportunity for improvement. Ashleigh Manor DS0000003570.V330772.R02.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 X X X X X 2 1 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 1 Ashleigh Manor DS0000003570.V330772.R02.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO 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 OP9 Regulation 13(2) Requirement All medicines must be recorded into the home and ointments only used for those for whom they are prescribed. This protects residents from errors. Storage of medicines must be fully secured in robust cupboards or trolleys so that no one other than delegated staff can access them. The home must be kept thoroughly clean, 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 safeguarding checks must be carried out, prior to a person starting work at the home, as described in Schedule 1, to protect residents from people unsuitable to work with vulnerable adults. Commodes must be fully cleaned and kept in a hygienic state to be pleasant and prevent the risk of infection. DS0000003570.V330772.R02.S.doc Timescale for action 30/04/07 2 OP9 13(2) 31/05/07 3 OP19 23 (2)(d) 31/05/07 4 OP25 13(3) 30/09/07 5 OP29 19(4) 30/04/07 6 OP26 13(3) 19/04/07 Ashleigh Manor Version 5.2 Page 25 7 OP38 13(3) 8 OP38 13(4) Residents must not be exposed 30/04/07 to unnecessary health and safety risks therefore: - Toothpaste must not be kept with ointment prescribed for external use as one may be used instead of the other. - Cleaning chemicals must be kept securely to protect confused residents. - Fire doors must not be propped open and pose a risk in the event of fire. Residents must not be exposed 31/05/07 to unnecessary health and safety risks therefore: - Wardrobes need to be properly secured to ensure they won’t fall. - The electric socket in room 5 must be moved to a wall location to ensure the wires remain intact. - Carpets must be even and not pose a trip hazard to residents. 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 OP4 Good Practice Recommendations The needs of residents with dementia should be better met through specialist environmental adaptations which aid the orientation of confused people, management of the lounge environment (noise) to improve social opportunities, and continued staff training in dementia care and the reduction of unnecessary risks in the home environment. Two staff should record that hand written entries into the medical records are correct to reduce the possibility of a mistake being made. 2 OP9 Ashleigh Manor DS0000003570.V330772.R02.S.doc Version 5.2 Page 26 3 4 5 OP10 OP12 OP15 Residents should not be exposed to the indignity of having incontinence protection on their chair unless necessary and with their agreement. The activities available should be more reflective of what residents want. The food provided/menu should be more reflective of what residents want. Ashleigh Manor DS0000003570.V330772.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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