Inspection on 02/04/08 for Ashleigh Rest Home,

This inspection was carried out on 2nd April 2008.

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

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 Rest Home, 27/02/09

Ashleigh Rest Home, 24/08/06

Ashleigh Rest Home, 14/12/04

Ashleigh Rest Home, 01/07/04

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

CARE HOMES FOR OLDER PEOPLE Ashleigh Rest Home, 19 Upper Walthamstow Road Walthamstow London E17 3QB Lead Inspector Rob Cole Unannounced Inspection 2nd April 2008 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ashleigh Rest Home, DS0000007219.V361778.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 Rest Home, DS0000007219.V361778.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashleigh Rest Home, Address 19 Upper Walthamstow Road Walthamstow London E17 3QB 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) 020 8520 0671 Mr Yusuf Oomar Jooma Mrs Rooksanah Jooma ****Post Vacant**** Care Home 10 Category(ies) of Old age, not falling within any other category registration, with number (10) of places Ashleigh Rest Home, DS0000007219.V361778.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd May 2007 Brief Description of the Service: Ashleigh Rest Home is a privately owned care home registered to provide support and accommodation to 10 service users over the age of 65. The home is in a quiet residential road in the London Borough of Waltham Forest with easy access to local shops, transport networks and local amenities. Accommodation is provided on two floors with one shared bedroom on the top floor. The current range of fees charged by the home is between £400 and £410 per week. Ashleigh Rest Home, DS0000007219.V361778.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The inspection took place on the 2/4/08 and was unannounced. The inspector had the opportunity of speaking with service users and staff. The homes acting manager was present throughout the course of the inspection, and the homes proprietor was present for part of the inspection. The inspection also included an examination of records and other documents, along with a tour of the premises. The inspector had the opportunity of observing staff interactions with service users. Prior to this inspection, the home completed an Annual Quality Assurance Assessment (AQAA) at the request of the CSCI. Several surveys were also completed by service users and relatives, and these contributed to the overall inspection process. What the service does well: What has improved since the last inspection? What they could do better: Ashleigh Rest Home, DS0000007219.V361778.R01.S.doc Version 5.2 Page 6 Despite these improvements, there are still a number of issues that must be addressed. In particular, the home must ensure that all staff undertake appropriate adult protection training, and that an up to date adult protection policy and procedure is in place. The home must appoint a registered manager and apply for their registration with the CSCI. 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 Rest Home, DS0000007219.V361778.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 Rest Home, DS0000007219.V361778.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): 1,2,3,4 and 5. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that prospective service users would have the opportunity of visiting the home before making any decision about moving in. However, the home must ensure that service users are provided with relevant information about the home, for example through the Statement of Purpose and written contracts. EVIDENCE: The home has a Statement of Purpose and Service User Guide in place, both documents are written in plain English. The Statement says that the aim of the home is “To maintain and increase the quality of life of the service user, to provide a environment that maintains individuality and self awareness and to Ashleigh Rest Home, DS0000007219.V361778.R01.S.doc Version 5.2 Page 9 make it possible that the service user maintains their dignity and independence.” The Statement includes information on the facilities and services provided along with the aims and objectives of the home. However, as at the last inspection, the Statement has still not been subject to regular review, and still contains inaccurate and out of date information. For example, the details of the manager are of someone who no longer works at the home, while the Statement says that the home will provide support for people with dementia, but the home is not registered for this. In order to help ensure that prospective service users are provided with accurate and comprehensive information about the home, it is required that the Statement of Purpose is up to date, and subject to regular review. The Service User Guide is in line with National Minimum Standards (NMS). It includes details for the provision of activities in the home, and a copy of the homes complaints procedure. At the previous inspection a requirement was made that service users are provided with a written contract or statement of terms and conditions, which sets out what the fees for the home are, along with what these cover. There was no evidence that a contract has subsequently been provided for any of the current three service users living at the home, and therefore this requirement is repeated in this report. There have been no new admissions to the home since the last inspection, and for the existing service users there was evidence that pre admission assessments were carried out before they moved into the home. The AQAA supplied by the home makes clear that service users would be able to visit the home before making a decision as to move in or not. The homes admissions procedure also states this. It goes on to say that any placement would be subject to review. The home does not provide intermediate care. Ashleigh Rest Home, DS0000007219.V361778.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 and 11. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that the home is generally meeting the health and personal care needs of service users. Care plans are of a good standard, and service users have assess to relevant health care professionals as appropriate. EVIDENCE: All service users have an individual care plan in place. The inspector was pleased to note that these have improved considerably since the previous inspection, and are now of a satisfactory standard. Care plans are drawn up with the involvement of the service user, their keyworker and the homes acting manager, and are subject to regular review. Plans cover needs around health, medication, mobility, social and leisure needs as well as needs around equality and diversity issues such as culture and disability. Ashleigh Rest Home, DS0000007219.V361778.R01.S.doc Version 5.2 Page 11 Risk assessments for service users are in place, and as with care plans these are of a good standard and subject to review. Assessments identify any potential risk, and include strategies to manage and reduce those risks. Assessments cover risks around mobility and falling, and support with personal care and lifting. All service users are registered with a GP. Since the previous inspection the home now keeps clear and comprehensive records of all medical appointments, including details of any follow up action required. These records evidenced that service users have routine access to health care professionals as appropriate, including dentists, opticians and chiropodists. There was evidence that service users were supported to have flu jabs at the beginning of last winter. The home also carries out regular health related checks, for example checking the weight of service users. The home provides a regular gentle exercise class to help promote the fitness and general wellbeing of service users. The home makes use of the Continence Advisory Service, who supply advice and continence products. Used continence products are stored in yellow bags, which are kept in the back yard prior to collection. However, they are not stored in a bin, and are accessible to animals, which could lead to the spread of infection. In order to counter this used continence products must be stored in a container that includes a lid, which would make them inaccessible to any animals. Medications are stored in a locked cabinet, and all staff undertake training before they are able to administer medications. The home has a policy on medication, but this needs further development to be fully in line with NMS. For example, it includes no information on what to do if an error occurs while administering medication, or around self medicating service users. It is required that the home has a comprehensive policy on the ordering, receipt, handling, storing, administering, disposal and recording of medications, to help ensure that service users always receive any medications as appropriate. Medication administration record charts are maintained by the home, those checked by the inspector appeared to be accurate and up to date. Through observation and discussion there was evidence that the home seeks to promote the dignity and privacy of service users. Care plans make it clear that service users are supported with their personal care in a sensitive manner, and are encouraged to manage their own personal care as far as possible. Staff were observed to knock and wait for an answer before entering bedrooms. Service users are given their own mail to open, and have access to a telephone, which they can use in private. The acting manager informed the inspector that service users would be able to remain in the home with a terminal illness, so long as the home was able to meet their medical needs. Ashleigh Rest Home, DS0000007219.V361778.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that service users are supported to live valued and fulfilling lives, and that food provided is of a good standard. EVIDENCE: The home provides a variety of social and leisure activities. An outside professional visits the home fortnightly to provide a gentle exercise class for service users, those spoken to informed the inspector that they enjoyed this. Service users have access to foot spa’s, music, television, board games reminiscence and sing-a-longs. Indeed, staff and service users were engaged in a sing-a-long session during the inspection, which service users appeared to be enjoying. A visiting library visits the home, which supplies audio books, thus helping to meet needs around equalities and diversity around visual impairments. Service users are able to access the local community, for example visiting shops. Ashleigh Rest Home, DS0000007219.V361778.R01.S.doc Version 5.2 Page 13 Visitors are welcome at the home at any reasonable time, and are able to see service users in private. As part of this inspection process, surveys were issued to relatives and friends of service users, and these provided generally positive feedback. One commented that “They make it as homely as possible.” While another said “My friend is well cared for and happy.” Through observation and discussion there was evidence that service users have a large measure of control over their daily lives, for example what time to get up and go to bed, or what clothes to wear. All service users were appropriately dressed on the day of inspection. The new acting manager has recently re-introduced service user meetings to the home, and they informed the inspector that they plan to have these on a monthly basis, to provide service users with the opportunity of been involved with the running of the home. Records are maintained of menus, and these indicated that service users are offered a varied, balanced and nutritious diet. Service users were observed to be offered a choice for lunch on the day of inspection, and meals prepared appeared appetizing and healthy. Support provided with mealtimes was done in a sensitive manner, and service users spoken to said they liked the food at the home, one commented that “My lunch is very nice.” The home helps to meet needs around equalities and diversity through the provision of food, for example it regularly cooks traditional English and Jamaican food. The kitchen was clean and tidy and food was stored appropriately. Records are maintained of fridge and freezer temperatures, and all staff involved in food preparation have undertaken food hygiene training. Fresh fruit was available, and drinks and snacks were offered to service users throughout the course of the day. Ashleigh Rest Home, DS0000007219.V361778.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 and 18. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspector’s view that the home has appropriate systems in place around complaints, but that more must be done to help ensure that service users are safeguarded from the risk of abuse. EVIDENCE: The home has a complaints procedure, a copy of which was prominently displayed within the home, giving service users and others access to it. The inspector was pleased to note that since the previous inspection the home now also has a complaints log, which is used to record any complaints received, including details of any investigations and outcomes. This log indicated that the home has investigated complaints received in an appropriate manner. There was evidence that the home seeks to protect and safeguard the legal rights of service users, for example, as mentioned, service users have routine access to health professionals and are registered with a GP. All service users are on the electoral register, and are able to vote in elections if they choose. Ashleigh Rest Home, DS0000007219.V361778.R01.S.doc Version 5.2 Page 15 The home has a copy of the Local Authorities adult protection procedure. However, there was no evidence that it has its own policy on adult protection. To help ensure that service users are protected from abuse, the home must have a comprehensive adult protection procedure, which includes details of what staff need to do in the event of an adult protection allegation been made. The inspector was disappointed to note that not all staff have as yet undertaken adult protection training, despite this been an outstanding requirement from the previous inspection, there was evidence that some staff have had this training, but not all, and the acting manager has not undertaken any adult protection training. The requirement is repeated in this report, to ensure that all staff are knowledgeable about their responsibility with regard to adult protection issues. Ashleigh Rest Home, DS0000007219.V361778.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 and 26. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that the home is suitable to meet its stated purpose with regard to the physical environment. The home was generally well maintained, and service users are provided with adequate communal and private space. EVIDENCE: The home is situated in the Walthamstow area of the London Borough of Waltham Forest. The home is in a quiet residential area, close to shops, transport networks and other local amenities, and is in keeping with other homes in the vicinity. Ashleigh Rest Home, DS0000007219.V361778.R01.S.doc Version 5.2 Page 17 The communal areas of the home consists of a dining room, sitting room, conservatory, kitchen and garden. The garden was well kept, and had appropriate garden furniture. The home was generally well maintained, both internally and externally. Fixtures and fittings around the home were domestic in character, and generally well maintained, and the inspector was pleased to note that the stained hallway carpet has been replaced since the last inspection. The home had adequate numbers of toilets and bathrooms to meet service users needs. Toilet facilities have been adapted to make them accessible to all service users. Bathrooms were clean and tidy, and free from offensive odours. However, the ground floor toilet did not have a working lock, while the first floor toilet had a lock which did not include an emergency override device. To help ensure the safety and privacy of service users, it is required that all bathrooms and toilets within the home are fitted with a working lock, which includes an emergency override device. The home has eight single bedrooms and one double bedroom. None of which are ensuite, but all have a hand basin. Bedrooms had adequate natural light and ventilation, and all were centrally heated. Bedding, carpets and curtains were well maintained and domestic in character. Rooms have been personalised to service users individual tastes, for example with family photographs, and were clean and tidy. Adequate furniture was provided, including table, chairs, wardrobes and chest of draws. Bedrooms meet NMS on size requirements. Laundry facilities were of an appropriate scale for the home, and hand washing facilities were situated around the home. Protective clothing such as gloves and aprons are available to staff, to help control the spread of infection. COSHH products were stored securely. Ashleigh Rest Home, DS0000007219.V361778.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspector’s view that the home is staffed in sufficient numbers to meet the needs of service users, and that staff have a good understanding of their roles and responsibilities. However, the home must ensure that all appropriate employment checks are carried out on staff, including CRB checks and employment references. EVIDENCE: The home provides 24-hour staff support, including waking night staff and an emergency on-call procedure. There was a staffing rota on display within the home, and this accurately reflected the staffing situation on the day of inspection. For much of the time, the home operates with only one member of staff on duty. The home is registered for ten people, but at the time of inspection only three people where residing at the home, and the inspector considers current staffing levels to be adequate, although these would need to be reviewed if there were any further admissions to the home. Ashleigh Rest Home, DS0000007219.V361778.R01.S.doc Version 5.2 Page 19 Through observation and discussion there was evidence that staff have a good understanding of the needs of service users, and that they have built up good relations with individual service users. Staff were seen to interact with service users in a friendly and respectful manner, and examples of positive interactions were seen during the inspection, for example with mealtimes and sing-a-longs. Staff were seen to have a good ability to communicate with service users. Six of the nine care staff working at the home have achieved a relevant care qualification, well above the 50 of staff required by the NMS. The acting manager informed the inspector that it is planned that two more staff will start working towards a relevant qualification in the near future. All staff undertake a structured induction programme on commencing work at the home, this includes service user issues and the homes physical environment. Records are maintained of staff training, and recent training includes food hygiene, oral care, dementia and infection control. The home has policies in place on equal opportunities and recruitment and selection. The inspector checked staff employment files, these were all found to contain proof of ID. However, for two staff there was no evidence of any written employment references, and for one member of staff there was no evidence of a CRB check been carried out by the home. They had a CRB check from a previous employer, but these are not portable, and it is required that the home carries out an enhanced CRB check for all staff working at the home, to help ensure that service users are protected from the risk of abuse, and a requirement has been made around this. Ashleigh Rest Home, DS0000007219.V361778.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37 and 38. People who use this service experience adequate in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that the home must appoint a permanent manager, who is registered with the CSCI, to help ensure that the home is run effectively and appropriately. EVIDENCE: The home currently does not have a registered manager in place, but has an acting manager who is responsible for the day to day running of the home. It was found at a previous inspection of the home on the 24/8/06 that there was no registered manager in place, and a requirement was set around this. There Ashleigh Rest Home, DS0000007219.V361778.R01.S.doc Version 5.2 Page 21 was still no registered manager in place by the time of the next inspection on the 3/5/07, and the requirement was repeated. This requirement is repeated again in this report, and continued failure to comply with this may lead the CSCI to take enforcement action against the home. This issue was discussed with the homes proprietor during the course of the inspection, the proprietor assured the inspector that they planned to apply to register a manager with the CSCI in the near future. The acting manager did present as having developed good relations with service users and staff, who informed the inspector that they found the acting manager to be approachable and accessible. Record keeping within the home was of a generally good standard. Confidential records are stored securely, staff and service users can access their records as appropriate. Written records are maintained of financial transactions involving service users money. All staff receive regular formal supervision either from the homes acting manager or it’s proprietor. Written records are maintained, and staff and service users can access these records. Supervision covers performance, training needs and service user issues. Care plan reviews, staff supervision and service user meetings all contribute to the quality assurance process within the home. Questionnaires are issued to relatives to gain their views on the running of the home. Completed questionnaires seen by the inspector contained generally positive feedback, with comments such as “The carers are very helpful.” And “I find the staff competent and they put smiles on the residents faces.” Copies of previous inspection reports were available to view in the home. However, the home could only evidence that it has had three Regulation 26 inspections within the past twelve months. It is a repeat requirement from the previous inspection that the home has monthly unannounced Regulation 26 inspections, and that a copy of the report of these visits is available to view within the home. Fire extinguishers are situated around the home, and were last serviced in October 2007. Fire exits were clearly signed and free from obstruction. Fire alarms are checked weekly, and were last serviced by an engineer on the 25/3/08. The emergency lights and the service lift are also routinely serviced. The home had in date safety certificates for PAT testing, gas safety and electrical installation, as well as in date employer’s liability insurance cover. The home checks fridge and freezer temperatures and hot water temperatures. COSHH products are stored securely. Ashleigh Rest Home, DS0000007219.V361778.R01.S.doc Version 5.2 Page 22 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 2 1 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 3 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 3 18 2 3 3 2 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 3 2 X 3 3 3 3 Ashleigh Rest Home, DS0000007219.V361778.R01.S.doc Version 5.2 Page 23 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 OP31 Regulation 8 Requirement The registered person must ensure that a permanent manager is appointed to the home, and that they apply for registration with the CSCI. (Timescale 31/08/07 not met) The registered person must ensure that the homes Statement of Purpose is dated, subject to regular review, and that it contains accurate and up to date information. (Timescale 30/06/07 not met) The registered person must ensure that all service users are provided with written contracts/statement of terms and conditions, containing all information required by NMS 2. (Timescale 31/08/07 not met) The registered person must ensure that all staff working at the home undertake appropriate training in adult protection issues. (Timescale 31/08/07 not met) The registered person must ensure that satisfactory CRB checks are carried out on all staff DS0000007219.V361778.R01.S.doc Timescale for action 30/06/08 2. OP1 4 30/06/08 3. OP2 15 30/06/08 4. OP18 13 and 18 30/06/08 5. OP29 19 30/06/08 Ashleigh Rest Home, Version 5.2 Page 24 6. OP33 26 7. OP8 13 8. OP9 13 9. OP18 13 10. OP21 23 employed at the home, and that they have two written employment references. (Timescale 31/08/07 not met) The registered person must ensure that monthly unannounced Regulation 26 visits are carried out, and that a copy of the report of these visits is forwarded to the CSCI, and a copy retained within the home. (Timescale 30/06/07 not met) The registered person must ensure that used continence products are stored appropriately in a container/bin that includes a lid. The registered person must ensure that the home has a comprehensive policy in place on the ordering, receipt, storing, recording, administering and disposal of medications within the home. The registered person must ensure that the home has a comprehensive policy in place on adult protection, which is in line with current legislation. The registered person must ensure that all bathroom/toilet doors are fitted with working locks, that include an emergency override device. 30/04/08 30/04/08 30/04/08 30/04/08 30/06/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ashleigh Rest Home, DS0000007219.V361778.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection London Regional Contact Team Caledonia House 223 Pentonville Road London N1 9NG 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 Rest Home, DS0000007219.V361778.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!