Inspection on 19/05/06 for Ashleigh Manor

This inspection was carried out on 19th May 2006.

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 19/04/07

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 Antonia Reynolds Unannounced Inspection 19th May 2006 11:15 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.V290532.R01.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.V290532.R01.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 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.V290532.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Five service users Category PD 50yrs Date of last inspection 19th October 2005 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. The home does not accommodate people who display challenging behaviour or aggression. The home does not provide intermediate care but does accept a small number of service users who require short term respite care. It is privately owned by Mrs Maureen Lawley and Ms Loretta Maher-Lawley. The Registered Manager is Mrs Maureen Lawley. From April 2006 the fee levels were between £320 and £387 per week. Information about the service can be obtained from Mrs Lawley. The home was opened in 1989 and 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 so that there is a lot of choice of areas for relaxation or activities to take place. 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 attractive garden to the rear of the property. Ashleigh Manor DS0000003570.V290532.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection consisted of an unannounced visit and two further visits. The first visit took place between 11.15am and 1.45pm on Friday, 19th May 2006, the second between 9.30am and 5.50pm on Wednesday, 31st May 2006 and the third between 9.30am and 1pm on Monday, 12th June 2006. One of the Registered Providers, Loretta Maher-Lawley, was present on all three visits and Maureen Lawley was also present on the 2nd day of inspection. A tour of the premises took place and records/documents relating to the care of the service users, staff and the home were inspected. A pre-inspection questionnaire had been completed by the Registered Provider, which contained information relevant to the inspection. Survey forms had been completed by six service users and twenty-four service users were spoken with or observed during the visits. Fifteen were spoken with at greater length. Relatives and other individuals/agencies involved with the home were written to and asked their views of the home. Replies were received from two relatives who expressed satisfaction with the care being provided. Three responses were received from health and social care professionals who generally expressed satisfaction about the care provided, although have highlighted the need for better communication about health care needs, but this is already being addressed by the management team. What the service does well: What has improved since the last inspection? Risk assessments relating to personal and health care needs have been completed, as well as manual handling and falls assessments. A new induction programme had been introduced for new staff and all employment records were available. A quarterly newsletter has been produced so people know what is happening in the home. The Registered Providers have continued with their action plan from previous inspections: radiators are being covered; heat reflecting material has been Ashleigh Manor DS0000003570.V290532.R01.S.doc Version 5.2 Page 6 ordered for the conservatory area to provide shade in direct sunlight; new laundry equipment has been purchased and installed; portable electrical appliances have been checked for safety; some rooms and hallways have been redecorated and refurbished to a good standard; the extractor fans in the kitchen have been replaced. 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 Manor DS0000003570.V290532.R01.S.doc Version 5.2 Page 7 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.V290532.R01.S.doc Version 5.2 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users and their representatives can be confident that they will be given clear information to help them make a choice about this home. EVIDENCE: A Statement of Purpose and Service User Guide were available for prospective service users with a clear and easy to read description of the services provided. A book entitled “About Ashleigh Manor” was in the main entrance and provided further information for service users and families. It is designed to answer the more common questions raised when moving into a care home. This book also details future plans for the home and the development of new services, such as a meditation room and complementary therapies. The Manager was considering updating this again focussing on the issues that are important to service users. The pre-admission assessment process ensured that the needs of prospective service users were identified and they had opportunities to visit the home prior to admission. The Manager confirmed that every service user has been provided with a contract and/or statement of terms and conditions. Discussions with service users, staff and the Ashleigh Manor DS0000003570.V290532.R01.S.doc Version 5.2 Page 9 management team, as well as observation, showed that staff were aware of the needs of the service users. The home did not provide intermediate care. Ashleigh Manor DS0000003570.V290532.R01.S.doc Version 5.2 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can feel confident that their personal and health care needs will be met. EVIDENCE: Service users’ files contained care plans that had recently been updated and were regularly reviewed. Risk assessments relating to health and personal care needs, as well as manual handling assessments, were completed during the inspection process. Discussion with service users, staff and the management team, as well as observation and information from relatives, confirmed that personal care was maintained, service users could bathe when they chose to and were encouraged to be as independent as possible. Information contained in care plans showed that service users had access to health care service services such as doctors, district nurses, the continence advisor, the mental health team and speech and language therapists. The Manager confirmed that referrals were made to other relevant professionals when required. Service users were treated with dignity and privacy was respected. Service users could use the home’s telephone or have private telephones installed in their bedrooms at their own expense. Those service users able to comment said that they were very well looked after by staff who Ashleigh Manor DS0000003570.V290532.R01.S.doc Version 5.2 Page 11 were kind, caring and helpful. Staff were observed treating all the service users with respect. Information from a relative indicated that personal and health care needs were carefully monitored and managed well by the staff team. Feedback from health and social care professionals highlighted the need for better communication about health care needs between staff and other professionals. The management team in the home confirmed that they were aware of this and were taking action to address it, for example, reorganisation of the staff teams and ensuring that the senior person in charge of each shift has an easy and quick way of recording information when it is given. A discussion took place with the management team about ensuring that all accidents are monitored to look for any possible patterns and making referrals where appropriate, for example to the falls team. The Manager confirmed that the home had five mattresses for pressure area care and there was a reliance on the health service to provide additional equipment when needed. A discussion took place about the delay this may cause and advice was given to consider investing in more equipment, such as mattresses and cushions, specifically for those people identified as being at risk of developing pressure sores. The home used a monitored dosage system for medication and practices relating to its administration were satisfactory. The home had a refrigerator specifically for storing medicines that needed to be kept at low temperatures. The home’s practice was to keep all eye drops and creams in this refrigerator and advice needs to sought from the home’s pharmacist about which eye drops and creams should be kept in the ‘fridge and which should be kept at room temperature. The Deputy Manager confirmed that action is taken if they find staff are not complying with the home’s medication policy, for example, by leaving the medication trolley unlocked. The home’s policy encouraged service users to be self-medicating and keep their own medication in their rooms, subject to risk assessment. Service users confirmed that they retained their own medication and were provided with lockable space in their rooms to keep it. The management team were considering ways of improving the administration of medication to better ensure that correct procedures are always followed. Ashleigh Manor DS0000003570.V290532.R01.S.doc Version 5.2 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The routines in the home are relaxed and relatives and friends can be confident that they are welcomed. Dietary needs of service users are well catered for with a balanced and varied selection of food available that meets service users’ tastes and choices. EVIDENCE: Service users were very positive about the lifestyle in Ashleigh Manor. They said that they chose where they spent their day and the times they got up and went to bed. The quality of the food was praised and everyone said they had a choice of meals, although they did not always know what they would be getting. Some service users were aware that there was a written menu on the notice board but not all the service users were able to read it. A discussion took place with the management team about providing menus on the dining tables each day so that the service users would know what to expect. The home had four dining rooms, which meant that service users could eat their meals in a pleasant and homely environment rather than a room large enough to accommodate everyone. Service users also confirmed they could have meals in their rooms if they wished to. Information obtained from relatives, as well as observation, confirmed that visitors were welcomed at any time and were invited to join in any planned Ashleigh Manor DS0000003570.V290532.R01.S.doc Version 5.2 Page 13 activities. The Assistant Manager was the designated activities co-ordinator and activities were planned on a daily basis although some service users said they did not always choose to join in. A quarterly newsletter had recently been produced to let the service users know what was happening in the home. These included musical entertainments, relaxation sessions and occasional visits by staff from Plymouth museum when reminiscence talks took place. Trips out were planned during the summer and service users were aware of what these were, for example, to the Aquarium, The Hoe, Jennycliffe, Totnes, Paignton Zoo and to the theatre. Some of the service users said they had recently been to the circus at Central Park. Transport was arranged by staff and was usually taxis, including those that could take wheelchairs, and a minibus was hired for group outings. The staff at the home organised regular events such as summer and Christmas fetes, to which relatives, friends and neighbours were invited. Any profit from these went towards funding outings and social events. The home has taken up membership of the local multi-cultural centre so that the opportunity to attend is available for service users should they wish. Service users are provided with opportunities to attend church if they wish to do so, and a local minister visits the home regularly. Ashleigh Manor DS0000003570.V290532.R01.S.doc Version 5.2 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can feel confident that any complaints they have will be taken seriously and that their views are listened to and acted on. EVIDENCE: The home had a written complaints procedure and service users knew how, and to whom, to make a complaint should they need to. The Statement of Purpose and Service User Guide stressed the willingness of the Registered Providers and staff to receive comments about the home and to resolve any concerns raised. Those service users able to comment said that they had confidence in the management and staff team to resolve any issues as soon as they arise. However, service users also said they had no complaints about the home or the care they received. The home has joined a national advocacy scheme so that service users can have immediate access to advocacy should they request or need it. The home had an adult protection policy and procedure and a copy of the Local Authority’s Alerter’s Guidance. However, none of the staff have attended training related to the protection of vulnerable adults and this should take place to ensure that all staff are aware of the procedures to follow. There was a visitors book in the front hallway to record dates, times and names of all visitors to the home. Ashleigh Manor DS0000003570.V290532.R01.S.doc Version 5.2 Page 15 Ashleigh Manor DS0000003570.V290532.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users live in a pleasant home that is comfortable, warm and which provides sufficient facilities to meet their needs. EVIDENCE: Discussions with the service users confirmed that they found the home warm, spacious and comfortable. In addition to four lounge and dining rooms there was a library, a conservatory and a quiet area. These gave a feeling of living in a much smaller home and assisted service users with memory loss to become more familiar with the layout of the home. Due to the high temperature levels experienced in the conservatory during the summer, heat reflective material has been ordered, which should be fitted shortly. The home was found to be clean and free from offensive odours, infection control practices were satisfactory and infection control training for staff was planned. The laundry room had recently been refurbished with new machinery and the service users said they were happy with the way the laundry was Ashleigh Manor DS0000003570.V290532.R01.S.doc Version 5.2 Page 17 done. Staff at the home ensured that all clothes were labelled so that there was no confusion. Bedrooms were of a good size and nicely decorated, most of which had en suite toilet facilities and some had en suite showers and baths. Lockable storage facilities were provided in every bedroom. The garden was large and provided a pleasant, safe environment for service users. Maintenance staff ensured that repairs and re-decorating tasks were undertaken promptly. Radiator covers are being fitted in accordance with the home’s improvement plan. Ashleigh Manor DS0000003570.V290532.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are cared for by staff in sufficient numbers to meet the needs of those currently living in the home. Recruitment practices protect vulnerable service users. EVIDENCE: Observation and discussion with service users and staff confirmed that the staff team were respectful, polite, attentive and responsive to service users’ needs. Service users described the staff as very kind and caring and confirmed they responded promptly to requests for assistance indicating that there were sufficient staff to meet the needs of those currently living in the home. Care staff were supported by catering, laundry, domestic and maintenance staff, as well as the management team. The Manager has devised a system to assess the staffing levels required and confirmed that these were flexible depending on the service users’ needs. Staffing rotas were available in the home. There has been a rather high turnover of staff in the last year, therefore the management team have arranged a training programme to address this and the induction training has been improved to comply with Skills for Care requirements. Staff confirmed that they were expected to attend various training sessions and courses, including health and safety, emergency first aid, manual handling, fire safety, food hygiene, dementia awareness and National Vocational Qualifications. The home subscribed to the Journal of Dementia Care so that the management Ashleigh Manor DS0000003570.V290532.R01.S.doc Version 5.2 Page 19 were aware of up to date practices. A discussion took place about making the journals available to staff and highlighting relevant articles for staff to read. Recruitment processes were robust in that two written references were obtained as well as a Criminal Records Bureau (CRB) check and no staff were left unsupervised until a satisfactory CRB check was obtained. The staff files examined contained the required documentation. Ashleigh Manor DS0000003570.V290532.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a well managed home. The Registered Providers and the staff team strive to provide a stimulating, safe environment where service users are respected and rights are upheld. EVIDENCE: The home is owned and managed by Mrs Lawley and her daughter, Ms MaherLawley, both of whom have many years experience in running the care home. At the time of inspection Mrs Lawley was the Registered Manager but the intention is that Ms Maher-Lawley applies to be the Registered Manager in the near future. The service users or their families/representatives managed their financial affairs and none were administered by any of the management or staff team at the home. Service users said that they felt safe and secure in their home and that the home was well managed. Ashleigh Manor DS0000003570.V290532.R01.S.doc Version 5.2 Page 21 The kitchen was found to be clean and tidy indicating that regular cleaning took place. The extractor fans have been replaced. Records of ‘fridge, freezer and cooked food temperatures were recorded daily demonstrating that regular monitoring was undertaken. The environmental health officer had visited this year and the management team confirmed that any requirements or recommendations following this visit had been addressed. Inspection of the fire logbook indicated that the required weekly and monthly tests/checks of the fire alarm system/equipment had been done. Staff had received fire safety training and regular unannounced fire drills took place to ensure that the care staff, service users and visitors were aware of the procedure in the event of a fire. A discussion took place about devising a system where it was easy to check which staff had attended each session to ensure that the training schedule complied with the home’s fire risk assessment. Records showed that portable electrical appliances had been checked for safety and pre inspection documentation confirmed that the home had a five year electrical wiring certificate issued in January 2002. Equipment such as the shaft lift, stair lifts, hoists and bath lifts had been serviced recently, as had the gas system. The Manager confirmed that thermostatically controlled valves were fitted to all baths and to wash hand basins where required. In other areas of the home, the temperature of the hot water is controlled by the combination boiler setting. All accidents and incidents were documented and a discussion took place about ensuring that these were monitored to look for any patterns and decide whether referrals to outside agencies were required. One of the service users’ file inspected had some daily records missing, however the management team were sorting out all the files and putting a system into place to ensure this does not happen again. All staff were expected to undertake emergency first aid training and a discussion took place about considering whether senior staff need to be qualified first aiders and complete a more advanced course. The Manager confirmed that all windows above ground level had window restrictors fitted. One was found to be missing on the second day of inspection but the Registered Manager confirmed this would be rectified immediately. Staff supervision was provided formally and informally and included teaching sessions that addressed the changing needs of the service users. A quality assurance survey is sent 6-monthly to service users and their families and annually to visiting health care professionals to ensure that the home continues to meet service users’ needs and allows comment upon any areas for improvement. Service user meetings are held every three months to discuss all aspects of the day-to-day management of the home and the services provided. The Registered Providers undertake unannounced visits to the home Ashleigh Manor DS0000003570.V290532.R01.S.doc Version 5.2 Page 22 to review the quality of care being provided by the staff on duty. Senior care staff meetings are held every week to ensure consistency with service users’ care. The quality assurance system needs to be developed and expanded to include an annual internal audit and a published report detailing the results of the service user surveys. Ashleigh Manor DS0000003570.V290532.R01.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 4 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 Ashleigh Manor DS0000003570.V290532.R01.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. Standard Regulation Requirement Timescale for action 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 OP9 Good Practice Recommendations The home should consult with the local pharmacist about which eye drops and creams should be kept in the refrigerator and which should be kept at room temperature. The home should ensure that all staff attend training related to the protection of vulnerable adults. The quality assurance system needs to be developed and expanded to include an annual internal audit and a published report detailing the results of the service user surveys. The home should consider whether key staff, such as Team Leaders, complete a more advanced first aid course to become qualified first aiders. 2. 3. OP18 OP33 4. OP38 Ashleigh Manor DS0000003570.V290532.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Manor DS0000003570.V290532.R01.S.doc Version 5.2 Page 26 - 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!