Inspection on 19/01/07 for Ashleigh Residential Home

This inspection was carried out on 19th January 2007.

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

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

Other inspections for this house

Ashleigh Residential Home 30/05/06

Ashleigh Residential Home 14/10/05

Ashleigh Residential Home 09/05/05

Ashleigh Residential Home 19/10/04

Ashleigh Residential Home 21/07/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Ashleigh Residential Home Ashleigh Residential Home 60 Stile Common Road Primrose Hill Huddersfield HD4 6DE Lead Inspector Unannounced Inspection 19th January 2007 9:25 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 Residential Home DS0000060145.V328186.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 Residential Home DS0000060145.V328186.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashleigh Residential Home Address Ashleigh Residential Home 60 Stile Common Road Primrose Hill Huddersfield HD4 6DE 01484 514291 01484 515532 sarah.hirst@eldercare.org.uk 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) Eldercare (Halifax) Ltd Mrs Sarah Rose Hirst Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Ashleigh Residential Home DS0000060145.V328186.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th May 2006 Brief Description of the Service: Ashleigh is owned and operated by Eldercare (Halifax) Limited. The home was originally registered to provide personal care and accommodation for up to 33 older people, but at the providers request the registration was reduced to 25 in May 2005. Ashleigh is located approximately 2 miles from Huddersfield town centre and is accessible for public transport and local shops. It is a stone built detached property with a purpose built extension. There are gardens around the home and car parking at the front. There is ramped access to the home. Although not a secure unit, Ashleigh has a coded door lock for entry and exit. The home has one double and twenty-three single bedrooms with en-suite facilities (toilet and wash-hand basin) over two floors. There are three day/quiet rooms and a dining room on the ground floor. One of the day rooms has toilet facilities within and further toilet facilities are located near to the dining area and the two remaining day rooms. A passenger lift provides access to the first floor. Information about the home in the form of a statement of purpose, service user’s guide and the most recent CSCI inspection report are displayed in the home’s entrance area. Copies of these documents can also be requested from the home. On the 11.01.07 the registered person advised that home’s scale of charges were £342.99 to £395.00 per week. Additional charges are made for: hairdressing, chiropody, magazines, newspapers, personal clothing, toiletries and outings where a charge is incurred. Ashleigh Residential Home DS0000060145.V328186.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this inspection, one inspector made an unannounced visit to Ashleigh on 19 January 2007. The visit started at 9:25am and ended at 5.45pm. On the day of the visit there were 18 service users in residence. During this visit the inspector spoke with ten service users, one relative, four members of staff and the manager. The inspector read care records, audited a sample of medications, sampled staff recruitment and training records, examined food menus, health and safety documentation, some policies and procedures, made a brief tour of the building, made observations and shared lunch with service users. Before the visit, questionnaires were sent out to obtain the views of service users, relatives, GPs and health and social care professionals. Surveys were sent to all the service users at the home, one was returned; 17 relatives, seven were returned; four GPs, two were returned, and four health and social care professionals, none were returned. The inspection findings are also based on a range of accumulated evidence received by CSCI since the last inspection, for example, notifiable incident reports when service users are involved in an accident or incident. The home’s manager also returned a completed pre-inspection questionnaire to the Commission prior to the visit. The inspector would like to thank all those who contributed to the inspection process. What the service does well: Before service users are admitted to the home an assessment of need is obtained and service users and their representatives are welcomed to visit the home before making a decision to live there. Staff are caring and patient in their interactions with service users and service users made positive comments about staff. Positive comments such as “Staff are always friendly and welcoming” and we are “Very happy with the care and the relationship with us” were also received from relatives. The care home is well maintained and where refurbishment takes place this is to a good standard. Ashleigh Residential Home DS0000060145.V328186.R01.S.doc Version 5.2 Page 6 Meetings are held with service users to which relatives are welcomed. Staff meetings are also held. Such meetings provide people with an opportunity to make their views known about the service. What has improved since the last inspection? What they could do better: Improvements need to be made to some areas of record keeping so that all documentation required by legislation is available and up to date. The management and operation of the home’s medication system must improve so that service users are not placed at unnecessary risk. The registered person needs to ensure that service users’ privacy, dignity and independence is consistently upheld and promoted by providing appropriate levels of support, appropriate monitoring arrangements and by ensuring that staff always knock before entering service users’ private accommodation. Work needs to continue so that the home provides activities that meet service users’ needs and capabilities; this includes religious activities, so that service users have increased access to stimulation and their daily lives enhanced. Please contact the provider for advice of actions taken in response to this Ashleigh Residential Home DS0000060145.V328186.R01.S.doc Version 5.2 Page 7 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 Residential Home DS0000060145.V328186.R01.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 Residential Home DS0000060145.V328186.R01.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): 2 and 3. Standard 6 is not applicable. No service user moves into the home with out having had their needs assessed and been assured their needs can be met. Not all service users have received a copy of the contract/statement of terms and conditions with the home. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Pre-admission assessments were available on those files seen and a letter confirming that the home can meet the prospective service user’s needs is provided. The manager explained that a contract/statement of terms and conditions is enclosed with the placement confirmation letter or provided at admission However, neither of the service users whose files were inspected had a contract/statement of terms and conditions in place. (See Requirements.) Ashleigh Residential Home DS0000060145.V328186.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 Most, but not all, service users’ care and support needs are set out in an individual plan. A range of relevant professionals meet service users’ health care needs. Service users may, where appropriate, retain responsibility for their own medication. However, they are not fully protected by staff practice regarding medicines management. Service users feel they are treated with respect and their right to privacy is generally upheld. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Ashleigh Residential Home DS0000060145.V328186.R01.S.doc Version 5.2 Page 11 EVIDENCE: Some elements of care planning were good and were based on assessment information. Relevant risk assessments for nutrition, falls, and pressure area care were in place. And a service user said she was weighed by staff. There was evidence of service user involvement in the care planning process. And a care plan review questionnaire had been signed by the service user and their key worker. The home’s visiting policy also notes that relatives are encouraged to be involved in developing their relative’s plan and activities of daily living. It was evident that reviews had taken place, but changes about how a service user was to be supported following the review had not always been incorporated into the care plan. (See Requirements.) It was positive to note from staff meeting minutes that the manager is auditing care plans and associated records and raising issues with senior staff about record keeping to improve practice in this area. No social care plans were seen on the files inspected although it was evident from activity records that service users had opportunities and were supported to fulfil their identified social care needs. One service user said she had opportunities to go out and another spoke of being asked if they wanted to but had declined. (See Requirements). Service users reported and there was written evidence of health care input by GPs, District Nurses, Chiropodist and Optician. One service user said she saw her GP if she needed to. Two GPs returned survey forms, one was satisfied with the overall care provided at the home, one was not. Unfortunately, the inspector was unable to discuss the survey response with the GP concerned. It was evident from comments received that service users feel well cared for at the home. One service user said she was “very well looked after”. Relatives returning surveys also expressed satisfaction with the care provided to their relative. Medicines, including refrigerated items, are stored securely when not being administered. None of the current service users self medicate, although safe storage is provided should they wish to and be assessed as safe to do so. Staff responsible for medicines administration have received training from the pharmacist. The recording and administration of medicines needs to be improved, however, as not all medications audited could be reconciled with the records held. Also, although the administration of controlled drugs (CD) were recorded and countersigned on the MAR (Medicines Administration Record) Ashleigh Residential Home DS0000060145.V328186.R01.S.doc Version 5.2 Page 12 sheet, as well as in the CD book, a witness to the administration of the CD had signed the CD book when no other details had been recorded. (See Requirements). The inspector was with a service user when a staff member entered the service user’s room without knocking. However, service users reported, and it was evident from further observation that staff respect service users’ privacy and knock on their bedroom and toilet doors before entering. The home’s manager should reinforce the principles of privacy and respect with staff to ensure consistent good practice in this area. (See Recommendations.) A listening device is in place on the ground and first floor. Staff said this was so that night staff could hear if anyone was moving around on the corridors and they would know to go to them. This was also discussed with the manager. Alternative ways of monitoring service users’ safety must be introduced as the use of a listening device raises issues of privacy. (See Requirements.) Ashleigh Residential Home DS0000060145.V328186.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 Service users have some opportunities for social stimulation. And they maintain contact with family and friends. Service users can exercise choice and control over their lives. Service users have a choice of foods, which they generally enjoy. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As noted under the section on Health and Personal Care above, no social care plans were seen on the files inspected although it was evident from activity records that service users have had some opportunities to fulfil their social care needs. A programme of future activities was on display that included the celebration of special events, for example, Mother’s Day, Easter and the Harvest Festival. A slide show of local scenes has been arranged for March and a Valentine’s Day Ashleigh Residential Home DS0000060145.V328186.R01.S.doc Version 5.2 Page 14 sing-a-long has also been planned. The manager explained that there had been a lot of activities over the Christmas period. And to ensure that service users have an opportunity for social stimulation, activity time has been included on the staffing roster over a 7-day period starting from the week following this inspection. The rotas showed that activity time had been allocated. Activities were discussed at the service users’ meeting in November 2006 when ideas such as walks, going to the pub and to the garden centre were put forward. Although some activities have taken place, the manager explained that these have been hit and miss. A relative returning a survey commented that “More could be done with more staff”. The allocation of dedicated activity time for service users will, hopefully, provide greater opportunities for service users to engage in social activities. As discussed with the manager, a previous requirement regarding activities is carried forward. It was evident from discussion with service users that they have opportunities to go out into the local community. One service user explained that she was not an active person and that she preferred “to sit and watch” the comings and goings throughout the day. The manager reported that there are opportunities for service users to go out to a local place of worship but that they don’t want to go. She also explained that she is trying to get a minister of religion to visit the home. Visitors are welcome to the home at any reasonable hour and service users and relatives who returned comment cards confirmed that visits could take place in private. Service users confirmed that they could decide what time they got up and go to bed and where they liked to sit during the day. Service users were seen to come down for breakfast at different times throughout the morning and some, who were able, were seen to move freely around the home. Since the last inspection Ashleigh has received a “Healthy Choice Award” from Kirklees Council, which indicates that the home provides healthy food such as fresh fruit and vegetables, pulses in stews and full fat milk. Fresh fruits and vegetables were seen and service users said that they enjoyed the food, that there was choice and that they had enough to eat. Monitoring records were in place where there were concerns about service users’ food and fluid intake. And records show that healthcare professionals were also involved where concerns had been identified. Improvements have been made to the dining environment with tablecloths and place mats now in use. The manager explained that the dining room carpet is to be replaced in the near future. Ashleigh Residential Home DS0000060145.V328186.R01.S.doc Version 5.2 Page 15 The inspector made observations while sharing some lunch with service users. Although some assistance was provided to service users who required it, it was of concern to see one service user with poor eyesight struggling to locate and eat the food that had been placed in front of her with little explanation as to what the meal consisted of and where on the plate each item of food was located. Thus compromising dignity and independence. It was also of concern that the meal of frozen fish and oven chips was cooked by 11am and kept warm, even though lunch is served from 12-1pm. By the time the meal was served the food was dry and hard in parts and a service user remarked on this. The manager explained that food is not usually prepared so far in advance of serving the meal. However, a recommendation is made for the manager to carry out quality checks on food provision and to ensure that service users receive an appropriate level of support at meal times. (See Recommendations.) Ashleigh Residential Home DS0000060145.V328186.R01.S.doc Version 5.2 Page 16 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 Service users and relatives are aware of the complaints procedure and complaints received are listened to and acted upon. Service users are protected from abuse. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s complaints procedure is on display in the entrance area. The manager reported that no complaints have been received by the home in the last twelve months. Service users spoken with had no complaints about the home, but that if they did they would speak to the manager. Six of the seven relatives returning surveys indicated that they were aware of the complaints procedure and two had used it. One of the GPs returning surveys indicated that a complaint had been received about the home and that they were not satisfied with the overall care provided. Attempts were made to speak to the GP concerned but had been unsuccessful at the time of writing. A relative spoken with in response to a survey received after this visit to the home explained that although a formal, written complaint was not made to the provider, a concern had been raised verbally about laundry, which, although Ashleigh Residential Home DS0000060145.V328186.R01.S.doc Version 5.2 Page 17 addressed at the time, was a recurring issue. It was clear from the complaints record that concerns are not recorded. However, concerns can be seen as an expression of dissatisfaction with the service provided and should be recorded. A recommendation is therefore made for a record to be kept of all concerns raised, whether verbal or written, and the action taken by the registered person to address those concerns. (See Recommendations.) This would also give useful information to the service provider in terms of quality assurance. It was clear from discussions that service users feel safe at the home. A service user said she was “treated well” by staff and others commented that staff were “very nice” and “good”. A relative noted on a survey that “Staff are very patient with (relative)”. Records show that the majority of staff have received adult protection awareness training. The manager explained that remaining staff are booked to receive adult protection training in the near future. When asked staff were able to say what abuse was and the action to be taken was abuse to be seen or suspected. Ashleigh Residential Home DS0000060145.V328186.R01.S.doc Version 5.2 Page 18 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, 26 Service users live in a well maintained and safe environment which is clean, pleasant and hygienic. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Ashleigh is well maintained. Redecoration is ongoing and where redecoration has taken place this is to a good standard. One bedroom (room 28), currently unoccupied, is being renovated and equipment and items of machinery were stored there. The door was unlocked and therefore potentially dangerous to Ashleigh Residential Home DS0000060145.V328186.R01.S.doc Version 5.2 Page 19 any service user who may walk in. This was raised with the carer in charge at the time of the observation. (See Requirements.) Service users spoken with said they were happy with their rooms. It’s evident that service users are able to bring personal possessions with them when they move into the home. And equipment suited to service users’ needs is provided, for example, pressure relieving and movement and handling equipment. Service users made positive comments about the environment in general and the cleanliness of the home. There were no unpleasant odours on the day of this visit. One service user said “It’s always kept clean”. The laundry area, which is kept locked, was generally clean and tidy. However, to ensure that hygiene standards can be maintained, the laundry floor covering which is showing signs of wear and tear should be repaired or replaced. (See Recommendations.) Ashleigh Residential Home DS0000060145.V328186.R01.S.doc Version 5.2 Page 20 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, 20 Staffing levels are sufficient to meet the needs of current service users. Staff receive relevant training to ensure they are competent to do their jobs. Recruitment policy and practices support and protect service users. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From observation and rotas seen, staffing levels on the day of the visit were adequate for the number of service users in residence. Staff spoken with also felt that staffing levels were adequate to meet service users’ care needs. Six of the seven relatives returning surveys felt there was sufficient staff on duty. One noted “Staff are readily available but seem very busy”. There are some staff vacancies at the home, which are being recruited to. In the meantime agency staff are covering vacant shifts. Good progress has been made with staff training and it’s clear that the home’s management and staff have worked hard in this area. However, this needs to Ashleigh Residential Home DS0000060145.V328186.R01.S.doc Version 5.2 Page 21 continue to ensure that staff have the appropriate knowledge and skills necessary when providing care to older people. Seventy-seven per cent of care staff have an NVQ (National Vocational Qualification) or equivalent which is well in excess of the national minimum standard. The home’s management and staff should be commended on this. Details of future training covers abuse awareness, fire safety training and common induction standards. Two staff records were checked and contained the necessary information, references and checks required. This helps to ensure that only people who are suitable to work with vulnerable adults are employed. The recruitment process was confirmed in discussion with staff. The staff team, which is multi cultural, reflects the local community. Ashleigh Residential Home DS0000060145.V328186.R01.S.doc Version 5.2 Page 22 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 The registered manager is working hard to improve the service at Ashleigh. A quality assurance system is in place but is limited in its use. Service users’ financial interests are safeguarded. The health, safety and welfare of service users and staff are promoted and protected. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Ashleigh Residential Home DS0000060145.V328186.R01.S.doc Version 5.2 Page 23 Sarah Hirst, who is experienced in working with older people, is registered with the Commission for Social Care Inspection as the registered manager of the home. She is working towards the NVQ level 4 award in care and management. Staff spoke of Ms Hirst as being supportive and available for advice. One carer said she felt she had learned a lot from Ms Hirst. And a relative reported that “My contact with (the manager) and (a senior carer) show them to be very efficient and conscientious at all times. Ms Hirst is working hard to improve the quality of service provided at Ashleigh. However, further work is necessary to ensure that improvements are made particularly with regards to medicines management, as this is an area of weakness that has the potential to place service users at risk. A service user satisfaction survey was completed in September 2005, the findings of which were positive overall. The manager explained that a new quality audit has yet to be done. Legislation requires that any review of the quality of care allows for consultation, not only with service users, but their representatives. And the National Minimum Standards for Older People advise that the views of other stakeholders, for example, GPs and chiropodist, are also sought as to how the home is achieving goals for service users. (See Requirements and Recommendations). This would be useful, particularly in light of a GP survey that indicated a lack of satisfaction with the overall care provided by the home. Neither the manager nor the owner acts as appointee for any of the service users. The manager reported that service users receive their personal allowance to dispose of as they wish. A sample of monies audited during this visit was easily reconciled with records held. The home’s handyman carries out and records health and safety checks. Service and maintenance checks are also carried out on equipment at the home. However, an up-to-date gas safety record was not available at the time of this visit and as discussed with the home’s assistant group care manager, the registered provider is to confirm when the gas safety check has been carried out. (See Recommendations.) Ashleigh Residential Home DS0000060145.V328186.R01.S.doc Version 5.2 Page 24 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 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Ashleigh Residential Home DS0000060145.V328186.R01.S.doc Version 5.2 Page 25 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 Standard OP2 Regulation Requirement Timescale for action 28/02/07 2 3. OP7 OP7 4. 5 OP9 OP10 5(B)(1)(2) All service users must be (as provided with a amended) contract/statement of terms and conditions at the point of moving into the care home. 15 Following any reviews, the service user’s care plan must be updated as necessary. 15 Social care plans must be developed for each service user based on their interests, hobbies, preferences and capacities. 13(4)(c) Accurate medication records must be maintained. 12(4)(a) Service user’s privacy must be ensured, therefore, suitable arrangements other than a listening device for monitoring service users’ safety must be introduced. A range of activities that reflect service users’ interests, hobbies, preferences and capacities must be provided. (Timescale of not fully met. 28/02/07 22/03/07 28/02/07 22/03/07 6. OP12 16(2)(n) 28/02/07 Ashleigh Residential Home DS0000060145.V328186.R01.S.doc Version 5.2 Page 26 7. 8 OP19 OP19 13(4)(c) 23(4)(a) The registered person must 22/01/07 ensure that bedroom 28 is made safe. 28/02/07 The service provider must provide the Commission with written confirmation that the actions agreed in the fire officer’s report dated 14.03.06 have been completed. (Timescale of 20.06.06 not met.) Any review of the quality of care provided by the home must allow for consultation, not only with service users, but their representatives. Therefore, the views of service users’ representatives must be sought as part of any quality review. 31/03/07 9 OP33 24(2) Ashleigh Residential Home DS0000060145.V328186.R01.S.doc Version 5.2 Page 27 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. 2. 3. 4. Refer to Standard OP15 OP15 OP16 OP16 Good Practice Recommendations The manager should carried out quality checks on the food provided at mealtimes. The manager should ensure that service users receive an appropriate level of support at meal times. Action should be taken to raise service users’ and relatives’ awareness of the home’s complaints procedure. A log of complaints and concerns, whether written or verbal, should be kept which notes the nature of the complaint or concern, the outcome of any investigation and the action taken, where appropriate, to put things right The laundry floor covering should be repaired or replaced to ensure hygiene standards can be maintained. The registered manager should complete the NVQ level 4 qualification in care and management to support her in developing her management skills. The views of stakeholders, such as GPs, should be sought as part of the home’s quality review. The registered provider should inform the Commission when the gas safety check has been carried out. 5. 6. OP26 OP31 7. 8. OP33 OP38 Ashleigh Residential Home DS0000060145.V328186.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 Residential Home DS0000060145.V328186.R01.S.doc Version 5.2 Page 29 - 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. 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