Inspection on 20/11/07 for Ashleigh Manor

This inspection was carried out on 20th November 2007.

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

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

Other inspections for this house

Ashleigh Manor 05/10/09

Ashleigh Manor 08/04/09

Ashleigh Manor 13/10/08

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Ashleigh Manor 1 & 3 Vicarage Road Plympton Plymouth Devon PL7 4JU Lead Inspector Kim Fowler Unannounced Inspection 10:00 20 November 2007 th 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.V352105.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.V352105.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 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.V352105.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Five residents Category PD 50yrs Date of last inspection 19th April 2007 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. 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 £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. Ashleigh Manor DS0000003570.V352105.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over 1 day and started at 10:00am and finished at 4.00pm. The homes care manager was available throughout the inspection. The inspector made a tour of the building and spoke to most the residents and six visitors visiting at the time of the inspection. Documentation relating to the care planning process and the management of the home were examined. After the inspection two professional surveys were sent out. Any comments are in the relevant section of the report. What the service does well: What has improved since the last inspection? What they could do better: All Care Plans completed would enable the staff in the home to meet the needs of individuals. Areas of Health and Safety must be maintained to ensure the safety of people living at the home and this includes, all carpets must be even and secure. All lino must be secured to the floor and rug free from trip hazards. All radiators must be covered to prevent burns. Ashleigh Manor DS0000003570.V352105.R01.S.doc Version 5.2 Page 6 All rooms should be free from odours and all rooms must be clean and tidy. The window in one person bedroom must be fixed to ensure this person has a warm and draft free room. All staff must be aware of Infection control and in particular the importance of changing gloves and apron when assisting people with toileting and handling food, this will help stop the spread of infections. If the laundry room is vacant the door must be closed and the iron switched off. Any incidents affecting the well being of people living at the home must be reported to the Commission including people leaving the premises and any aggressive incidents. 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.V352105.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.V352105.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1/3/5/6.Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who are considering admission to the home can be confident that a full assessment with be completed before admission to ensure the home can meet their individual needs. EVIDENCE: During the inspection the inspector spoken to visiting family members and they were able to confirm they had received information about the home before admission. The files examined were for three people recently admitted to the home and for two people who have resided at the home for some time. Further examination of files found that each file contained a completed pre admission questionnaire. Ashleigh Manor DS0000003570.V352105.R01.S.doc Version 5.2 Page 9 Most people living at the home were spoken with during the visits. One relative of a new admission to the home stated that they had received information about the home and had assisted in the completion of an assessment to inform staff of their needs. All files held a completed pre-admission assessment, a care plan and additional information including personal care needs to support staff in the care of each individual living at the home. One family member confirmed they had provided the home with information about there relative before admission. The homes AQAA states that the home carries out a homes assessment prior to admission to ensure the home is able to meet the needs of people admitted to the home. Two Senior Care Staff or the management of the home completes this form. These document are important for prospective service users to assured them that not only can their health care needs be met but also their emotional, social, cultural or religious needs. One family member confirmed they had visited the home before their relative had moved in. Ashleigh Manor does not offer Intermediate Care. Ashleigh Manor DS0000003570.V352105.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. 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. People living at this home receive consistent health and personal care as appropriate. People are treated with respect and their right to privacy is upheld. All care plan completed would enable staff to meet the health and welfare needs of people living at the home. EVIDENCE: Five files were examined and four contained an individual care plan containing information on care needs and how the home would meet these needs. Evidence was recorded that care plans are updated and reviewed monthly by the designated key worker. 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. Ashleigh Manor DS0000003570.V352105.R01.S.doc Version 5.2 Page 11 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 are unable to express themselves verbally. Four care plans seen contain risk assessments and these are complete in detail. One relative confirmed that they had been involved in reviewing a care plan and the service provided due to the changing needs of their relative living at the home. However one care plan was not completed. All care plans should be completed to enable staff to be aware the individual needs of people living at the home at all times. The homes AQAA states, “Monthly updates of service user plan of care and the importance of service user plan of care to inform all staff and professionals to benefit each individual service user”. Evidence was recorded into individual files that people living at the home are referred to the District Nurse team and the Mental Health team after monitoring by the homes care staff. 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 GP’s, CPN (Community Psychiatric Nurse), chiropodist and consultants based at the local hospital. One relative stated that their family member had been referred to a specialist at the local hospital and was “pleased with the care and support offered by the home” during their family members illness. The manager discussed how the medication is stored, ordered and administered and that the home uses the blister system for dispensing medication. Thus providing evidence that the manager was aware of the policy and procedure for handling, administrating and recording medication. Several staff confirmed they had received medication training however the manager of the home carries out this training and the inspector would recommend that a local pharmacist be contacted to provide additional training. A previous requirement that the medication trolley and cupboards are secure has been carried out. Extra locks have been placed on the cupboards in the treatment room and the trolleys are now secured to the wall. Most of the people living at the home were spoken with during this inspection. Some were able to confirm that the staff treat them with respect and protect their privacy and dignity at all times. Observed during the inspection were staff Ashleigh Manor DS0000003570.V352105.R01.S.doc Version 5.2 Page 12 knocking on peoples doors to promote privacy and the Phlebotomist confirmed that all treatments are carried out in private. One relative who was visiting said, “The treatment and care is excellent”. A number of people living at the home said their personal care is always carried out in private. Ashleigh Manor DS0000003570.V352105.R01.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 good. This judgement has been made using available evidence including a visit to this service. The people living at Ashleigh Manor can be confident that the home offers good wholesome meals. The home welcomes and encourages families and friends to visit. EVIDENCE: A list of activities arranged is displayed on the homes notice board and activities favoured by individuals are recorded into care plans. Some of the people living at the home said that there are some activities organised however some people said they choose not to participate. A list of activities arranged for Christmas week is displayed on the homes notice board and this included a Carol service, Christmas lunch and Christmas party. One relative said “There is always something going on”. Visitors are welcome at any reasonable time and can visit their friend/family in the privacy of their own room or in one of the lounge areas around the home. Ashleigh Manor DS0000003570.V352105.R01.S.doc Version 5.2 Page 14 Two visitors spoken with and said they were able to visit whenever they wished and both stated that they are always made to feel welcome whatever time they visit. Many of the people living at the home said that they were able to have regular visits from family and friends. One person living at the home has their own car to go out whenever they wish. During a tour of the building most bedrooms were visited and provided evidence that each contains personal possessions. During a walk around the premises people were observed reading newspapers, watching TV and interacting with staff. Many were able to wander around the building freely and one relative said, “I know mum enjoys some of the activities offered”. The manager stated that the home does not manage any money for people living at the home. The home will bill family or next of kin for items such as hairdressing and chiropody. During discussion with people about food they said it was “very good”, “very nice”, and one person said “you won’t die from malnutrition here!” Several people also commented that they were able to make a choice on the food. Most people living at the home that were able to made positive comments about the food provided. The menus were displayed for all and the cook goes around each day to offer people choices for the main meal and for the tea meal. One cook was spoken with during the inspection and confirmed that the food budget was fine and there was always plenty of food available in the home including a choice of fresh vegetable. The meal observed being served at lunchtime was evidence that it was home cooked using fresh products. The meal was well presented and freshly prepared and consisted of a choice of Lemon Chicken or Beef Goulash and potatoes and fresh vegetables. The cook confirmed that fresh provisions were ordered regularly and there were always plenty of provisions available and everyday items could be obtained locally. Several relative said that the food seen served to their relative was always very good and plenty provided and also stated that they are routinely offered tea and coffee at every visit. Ashleigh Manor DS0000003570.V352105.R01.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): 16/18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home can be confident that any complaints or concerns raised will be listened to, acted upon and well managed by the home, which protects the welfare of all. EVIDENCE: Relatives spoken with stated that they were aware that the home had a complaints procedure. However they also stated that they have never needed to use it. They also felt they were able to approach the management of the home if needed and that any concerns or complaints would be acted upon and listen too. Many the people living at the home were spoken with and some were aware of the homes complaints procedure and stated that they had never had any need to use it. One informed the inspector “ I would talk to my son” and another said, “I have never needed to complain but would talk to Carol”. The designed complaints file held on recent recorded complaint. The actions and outcome of this complaint was also recorded providing evidence that this complaint was satisfactory dealt with. Ashleigh Manor DS0000003570.V352105.R01.S.doc Version 5.2 Page 16 The manager confirmed that 18 staff had completed the POVA (Protection of Vulnerable Adults) training with a local trainer. The manager and deputy had also completed the local authorities POVA training. The homes AQAA state that, “staff are aware of procedure for reporting issues (of abuse) to management and relevant outside bodies and organisations relating to Adult Abuse”. Ashleigh Manor DS0000003570.V352105.R01.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): 19/21/25/26. This outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Many areas of the home are pleasant and homely however areas were not maintained and provided a risk to people who live there. Adequate standards of hygiene put people at risk from infection. EVIDENCE: A full tour of the premises was undertaken and several issues of concern for health and safety were raised to the manager. The lino in one room was not secured to the floor, a carpet outside an en-suite was uneven and another room had a rug that was turned up on one edge all causing a trip hazards. Some room did not have radiator covers causing risk of contact burns however since the last inspection some rooms have radiator covers in place. Other Ashleigh Manor DS0000003570.V352105.R01.S.doc Version 5.2 Page 18 areas of concern included several rooms with an odour and some areas of the home were found to be dirty and unclean. One person living at the home reported that their window in their bedroom did not shut properly and had placed tissue around the gap to stop the cold and draught. Another person had a portable heater in their bedroom and said, “My radiator is not working”. The Manager said the radiator was working but this person chooses to leave it off. The manager would speak to the person concerned. Several bedrooms contained incontinence products for people to access however these rooms did not supply gloves or apron to assist staff with infection control. One staff member was observed assisting one person to the toilet and then entering the kitchen and providing a meal to this person with the same apron and gloves worn throughout. This practice could lead to the spread of infections within the home. The vacant laundry room had the door left open for anyone to access and the iron remained on during the inspectors visit to this area thus presenting a risk of burns and fire. The manager stated that other areas mentioned in the last inspection had been resolved including the light switch attached to the side of a free standing wardrobe, freestanding wardrobes which could have fallen and a bedroom door on the home’s automatic fire safety release system. The majority of the home was clean. Many of the people living at the home said the home was usually clean and tidy. One staff member confirmed that they had completed infection control training. One visitor spoken with said the hygiene of the home was “not always good” and another said their relaitives room was “always kept clean and immaculate”. The manager has links and is attached to the local infection control group and supports staff training in infection control. The homes AQAA states, “High level of control systems in place to control the spread of infections” and goes onto say, “Odours in Ashleigh Manor are pleasant and commented on regularly by visitors”. Ashleigh Manor DS0000003570.V352105.R01.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 good. This judgement has been made using available evidence including a visit to this service. The homes recruitment procedures protect people living at the home from being placed at risk of harm or abuse. Ongoing staff training is encouraged enabling people who live at the home to receive the best possible service. EVIDENCE: There is a training programme in place and First Aid training is booked for 2 weeks time. Many staff either holds and NVQ certificate or currently working towards this qualification and the homes AQAA says “continual staff training to ensure staffs knowledge”. The staff spoken with felt that most of the time there were sufficient staff on duty. But during time of sickness and leave it was more difficult. During the day of the inspection the home had only one employed domestic available, however a relief domestic was brought in to assist. One visitor agreed that they felt the home had sufficient staff on duty. The manager stated that 90 of staff holds on NVQ qualification and that most staff have completed POVA training. However the homes AQAA completed records that 50-60 of staff are trained in NVQ level 2 or above. The manager Ashleigh Manor DS0000003570.V352105.R01.S.doc Version 5.2 Page 20 stated that all staff shadowing other staff until clearance of CRB (Criminal Record Bureau) and staff records examined showed that all employment checks were in place ensuring so far as possible that only suitable staff are employed. The staff files examined each contained 2 written references, a Criminal Records Bureau check, and application form, contract of employment and job description. The manager said that the recruitment process includes standard interview questions. The staff files are stored securely and the files also included training certificates that confirmed that a variety of training is undertaken by staff. The manager confirmed that 18 staff had completed in-house dementia training and 4 main team leaders had completed a Dementia Awareness course. The manager and deputy manager had also completed a 3-day Dementia training course. Dementia training assists staff in understanding and meeting the needs of the people living at the home. Most of the people spoken with during the inspection made comments about the staff including “Very nice”, “lovely” and one person stated, “We are like one big happy family”. Ashleigh Manor DS0000003570.V352105.R01.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): 31/33/35/36/38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home is effective, ensuring that peoples needs continue to be met. EVIDENCE: Carol Mills the manager of the home assisted throughout the inspection. The Registered Manager and owners were not available. The manager stated that she has a good relationship with the owners and the Registered Manager and owner are around the home most days and available when needed. The manager has also completed Infection control training with the local Health Protection team and Dementia training providing evidence that the manager continues with her own professional development. Ashleigh Manor DS0000003570.V352105.R01.S.doc Version 5.2 Page 22 The AQAA goes onto to state that the home has restructured its management team to now include, 2 Proprietors/General Managers, 1 Home Manager, 1 Assistant Manager, 3 Team Leaders and 1 Lead Senior. Many of the people living at the home spoke highly of the management and comments included, “I can talk to Carol if I am unhappy” and a relative said, “I am always kept informed of what is going on with my relative and the management contact me when needed”. The manager said quality assurance questionnaires are sent out on a regular bases and includes family, friends, GP and other professionals. During the annual review and regular meeting held for all the people living at the home quality assurances issues are raised including the care people receive and the food served at the home. The home does not manage or hold any money for individuals living at the home and each person has a lockable cupboard in their rooms for the purpose. The manager said the home has no involvement in any finances and will bill family if any expenditure occures for example hairdressing. Staff supervision records showed that this is carried out regularly and on a one to one bases and the manager confirmed that they hold staff meetings. One staff interviewed confirmed that they receive supervision and this includes discussion on courses available. This staff also confirmed that they had received a yearly appraisal. Sampling of records indicated equipment is serviced regularly and maintained in good order. Health and Safety is a priority in the home and records examined showed fire safety training and fire protection is in place and up to date. However some incidents had not been reported to the Commission as required under Regulation 37. This included when people living at the home had left the building on a number of occasions and on one occasion with another person residing at the home also one person hitting out at a staff member. The manager confirmed all incidents are recorded in to the daily records of individuals and also an incident report is completed. The manager stated that the home would inform the Commission if people left the grounds of the front car park. Some areas of Health and Safety are not being met and these are reported under Standard 19. Ashleigh Manor DS0000003570.V352105.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 3 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 3 X X X 2 2 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 X 3 X 3 3 X 2 Ashleigh Manor DS0000003570.V352105.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES 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 OP7 Standard Regulation 15 Timescale for action All care plans must be completed 31/01/08 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 31/01/08 thoroughly clean and odour free, so that the environment is pleasant and hygienically safe for residents. All radiators and hot water pipes 31/01/08 must be guarded or have low surface temperatures to prevent the risk from contact burns. All procedure of infection control 31/01/08 must be adhered to protection people from infection. People living at the home must 31/01/08 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. Requirement 2 OP19 23 (2)(d) 3 OP25 13(3) 4 5 OP26 13 (4c) 13(3) OP38 Ashleigh Manor DS0000003570.V352105.R01.S.doc Version 5.2 Page 25 6 OP38 37 The Registered person must 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 events affecting service users in the care home. 31/01/08 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 OP19 Refer to Standard Good Practice Recommendations All windows should be able to be completely closed. Ashleigh Manor DS0000003570.V352105.R01.S.doc Version 5.2 Page 26 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. Extracts may not be used or reproduced without the express permission of CSCI Ashleigh Manor DS0000003570.V352105.R01.S.doc Version 5.2 Page 27 - 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!