Inspection on 24/08/06 for Ashleigh Rest Home,

This inspection was carried out on 24th August 2006.

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 Rest Home, 27/02/09

Ashleigh Rest Home, 02/04/08

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 Yemi Adegbite Unannounced Inspection 24th August 2006 12:27 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.V309476.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.V309476.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.V309476.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th December 2004 Brief Description of the Service: Ashleigh is a privately owned home catering for the needs of 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 and local amenities. Accommodation is provided on two floors in mostly single en-suite rooms with one shared bedroom on the top floor. Ashleigh Rest Home, DS0000007219.V309476.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and commenced at 12.27pm and conducted over a period of two days by the lead inspector together with a regulation manager. This inspection follows up requirements from the unannounced inspection held on 10th May 05. The inspector spoke to a service user, a relative, staff and the acting manager who was partly present during the inspection. The responsible person arrived at 1.10pm and stayed for the duration of the inspection. A tour of the environment was undertaken and samples of the homes records were examined and inspected together with a number of policies and procedures. An unannounced inspection gives the Commission an opportunity to access the home against the National Minimum Standard applicable to the service without the home having notice of the visit. What the service does well: What has improved since the last inspection? Ashleigh Rest Home, DS0000007219.V309476.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ashleigh Rest Home, DS0000007219.V309476.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.V309476.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,5 & 6 The quality in this outcome area is poor. This judgement had been made using available evidence including a visit to this service. None of the standards assessed at this inspection were met under this section. This does not assure service users of the type of care offered, or provide evidence to support appropriate admissions. EVIDENCE: The home is still running without a registered manager. A requirement was issued in the previous inspection report in regards to this issue, which was not met and is therefore repeated in this report. The responsible person was advised to address this as a matter of urgency ensuring that a permanent manager is in place. Ashleigh Rest Home, DS0000007219.V309476.R01.S.doc Version 5.2 Page 9 Evidence seen by the inspector indicated that the Statement of Purpose has not been amended in regards to the management changes. The document still contained details and qualifications of the previous manager that stopped working over 18 months ago. The responsible person must ensure that all relevant documents are amended and updated to reflect changes. A requirement was issued in the last inspection report, which was not met and will again be issued in this report. It was stated by the responsible person that service users are provided with relevant information about the home and service to be provided before admission. However, it was noted that a service user was admitted on an emergency basis, which is clearly not stated in the home’s Statement of Purpose. The responsible person must therefore ensure that the admission procedure is clearly stated and reflected in the home’s Statement of Purpose which should include: service users’ view of the home, a copy of the complaints procedure, and the number of places provided. Emergency admission policy should only however be included in the Statement of purpose if the home can demonstrate adherence to an effective policy and procedure. The service users guide was seen and deemed to contain relevant information as stated in the National Minimum Standards. It was however stated to the responsible person to ensure that relevant documents are amended and updated to reflect changes as evidence seen by the inspector suggested otherwise. The inspector saw evidence of a service user admitted on the 20th of July 2006 with no care plan undertaken after nearly five weeks of admission. This practice puts service users at risk of not having their key needs fully met following admission. The acting manager must therefore ensure that all service users admitted in an emergency are informed within 48 hours about key aspects, rules and routines of the service, and to meet all other admission criteria set out in standard 2-4 within five working days. The responsible person must ensure that a variation is applied for in respect of a service user who currently falls outside the homes category of registration. The responsible person stated that the staffing level is adequate for service users needs at the moment, as the home is not fully occupied. However the responsible person was advised to ensure that consideration is given to staffing levels with appropriate training in place to accommodate any future changes. The responsible person did however state that prospective service users are given the opportunity to visit the home and to move in on a trial basis before they make a decision to stay. Ashleigh Rest Home, DS0000007219.V309476.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8, & 9 The quality in this outcome area is poor. This judgement had been made using available evidence including a visit to this service. It was the inspector’s view that medication record was not being audited. The home was inspected on all key standards. EVIDENCE: Through observation during the inspection the inspector noticed that staff dealt with service users in a sensitive and dignified way, for example the inspector noticed through observation that staff were flexible offering a choice of meal to service users. Service users are also offered a range of support with regards to personal care, which could range from prompting to supervision. The responsible person stated that service users have regular contact with GP and community nurse and evidence was seen of a hospital visit recorded in the personal file. It was stated by the acting manager that chiropodist visits on regular occasions. A privately employed person also visited once a month to give armchair exercise however it was stated by the responsible person that Ashleigh Rest Home, DS0000007219.V309476.R01.S.doc Version 5.2 Page 11 this visit has not taken place for a couple of months now due to lack of interest from the service users. Three care plans were randomly selected and inspected. The care plans seen did not contain all the necessary details required in a care plan and where it did, information was not recorded on a regular basis. For example, a service users weight was last recorded on the 11/15/04 while the other files were inconsistent in regards to weight checking. A service user who had a fall on the 8/4/06 because staff “could not carry her weight” as recorded in the incident book, sustained a cut near her eye yet no evidence of a risk assessment was in place, which could have further highlighted ways to prevent an accident in the future. The inspector noted there was not a means in place to weigh service users who were not ‘weight bearing’. It was also noted by the inspectors that equipment in place were sometimes not used by staff for example, a service user with poor mobility sustained an injury to her eye because the right equipment was not used during transfer. It was disappointing that care plans were not reviewed in accordance to the National Minimum Standards for instance; evidence seen by the inspector indicated that a service user’s care plan was last reviewed on the 17/9/02. In respect of another service user identified as “high alert” as indicated on his care plan last had a review of his care on the 3/8/05. Most of the other care plans were out of date by months and some even years. The responsible person together with the acting manager must ensure that all service user’s care plans are reviewed at least once a month, updated to reflect changing needs and current objectives for health and personal care and actioned. It was however noted that the home had implemented ‘person centred planning’ which could be further improved to promote the on-going participation of service users and their representatives. The acting manager must also ensure that these care plans are daily working files. It was positively noted that medication is provided by the chemist in a blister pack with a photograph of each service user attached for easy identification. Medication records of the most recent service user admitted was inspected. This service user brought his own medication on the 20/7/06 but an audit was not undertaken to specify the exact amount of medication received by staff. The Prescribed medication Chlordiazepoide 5mg was entered on the MAR sheet “1 or 2 to be taken”. However, the directions on the pharmacy label stated “1 to be given”. This medication was administered on the 21/8/06 but no Ashleigh Rest Home, DS0000007219.V309476.R01.S.doc Version 5.2 Page 12 signature indicating this on the MAR sheet and at times when signed for, staff were not indicating the quantity administered. The responsible person was advised to clarify the required amount to be administered and to ensure that staff are signing the MAR sheet accordingly. Also medication brought in by service users or relatives must be audited and signed for ensuring easy accountability. Ashleigh Rest Home, DS0000007219.V309476.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14, & 15 The quality in this outcome area is adequate. This judgement had been made using available evidence including a visit to this service. It was the inspectors view that social and religious activities could be further developed for the wellbeing of the service users. EVIDENCE: Visitors are welcome in the home and two relatives were seen during the inspection. Both relatives spoken to stated that they were made to feel welcome and were happy with the care provided to their relatives. All visitors are required to sign the visitors’ book. Service users spoken to were generally happy however a service user raised concerns and felt his needs have not been properly met. This service user was admitted on the 20th July 2006 but no evidence of an assessment or a care plan was in place. The acting manager stated that an assessment had not been carried out because the service user came in as an emergency. The acting manager was therefore advised that all service users must have a full assessment carried out and a care plan implemented after five days of admission as clearly stated in the National Minimum Standards. Ashleigh Rest Home, DS0000007219.V309476.R01.S.doc Version 5.2 Page 14 This service user expressed his wishes to the inspectors that he would like to attend church on Sundays but this had not been noted by he home due to the lack of a care plan in place since his admission. A relative who visits on regular occasions stated that they have only witnessed staff playing a game of scrabble with service users once. It was stated by the responsible person that the home sometimes facilitate the wishes of service users by taking them shopping, for a walk and a service user is accompanied to the local Caribbean day centre on his request. However there was an absence of recording to demonstrate that this was the case. The only activity observed over the inspection period was a game of ‘snakes and ladder’, the radio was tuned to a contemporary station which was not suitable to service users needs. The acting manager and staff must therefore ensure that service users are given choice and opportunities for stimulation through leisure activities, which should be implemented from a comprehensive individual care plan. Evidence seen by the inspector indicated that meals provided are of a good standard. Hot lunch is prepared by a qualified cook Monday-Friday with service users having a choice of sandwiches for teatime prepared by the day staff (weekend lunch are prepared by the staff). It was positively noted that daily diets are recorded in the service users personal record book. Record of the fridge/freezer was inspected, although they were being recorded, temperature recorded exceeded the required temperature and no evidence was seen to demonstrate that actions were taken to ensure food was stored appropriately. The inspectors saw evidence that food was stored inappropriately for example, food in the fridge was not labelled, a tub of ice cream and opened tin of fish kept in a disused fridge. The inspector also noted that the fridge and freezer temperature had remained the same for the past six months (-30° reading for the fridge and -3° for the freezer). Evidence was also seen of false and inaccurate recording by staff who was signing the recording book on days when not rostered as working. This requires urgent improvement and will be issued as a requirement in this report. Ashleigh Rest Home, DS0000007219.V309476.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17, & 18 The quality in this outcome area is adequate. This judgement had been made using available evidence including a visit to this service. Appropriate policies and procedures for Adult Protection implemented; however, the home needs to ensure that all staff receives comprehensive training and guidance in relation to the whistle blowing policy. EVIDENCE: The home has a complaints procedure that was well displayed within the home. Examination of complaint records including investigations by the acting manager was satisfactory (last complaint recorded on the 25/4/05). A copy of the Adult Protection Policy for Waltham Forest was seen which the responsible person said is used in conjunction with the home’s policy. The benefits of having on going awareness and training for all staff were highlighted to the responsible person. Staff interviewed by the inspector were not fully aware and showed little understanding of the whistle blowing policy. The responsible person must therefore ensure that all relevant policies and procedure is facilitated and accessible to all staff. A requirement will be issued in this report. The responsible person stated that all service users are registered on the voter’s electoral list and have access to an advocacy service if need be. Financial records of service users are robust and recorded appropriately by the responsible person. Ashleigh Rest Home, DS0000007219.V309476.R01.S.doc Version 5.2 Page 16 Ashleigh Rest Home, DS0000007219.V309476.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,22,23,24,25, & 26 The quality in this outcome area is adequate. This judgement had been made using available evidence including a visit to this service. The home must however ensure that issues highlighted in this report are addressed to ensure a safe environment for all service users. EVIDENCE: Both the inspectors undertook a tour of the environment and the general view was that the home looked clean, comfortable and reasonably maintained. Most of the rooms occupied were adequate for their intended purpose however, it was noticed that room one was below the required size for an occupant with a physical disability who requires a hoist for transfers. The inspectors noticed stains on the carpet in room two which should be cleaned or replaced. Some areas of the floorboards were insecure and carpet in the landing area downstairs was worn out with torn areas noticed by the Ashleigh Rest Home, DS0000007219.V309476.R01.S.doc Version 5.2 Page 18 inspectors. This was a trip hazard. However, it was positively noted on the second day of the inspection that this had been temporarily fixed. It was noted that there was a significant gap between the floor and the wall in the downstairs toilet. The responsible person must ensure that urgent action is undertaken to rectify this. A member of staff confirmed that the light bulb in the corridor had not been working for more than a day and another light was without a lampshade. This is a potential hazard for service users with poor vision. The light switch in the entrance foyer needs to be investigated for electrical safety. Emergency cords were tested and functioning accordingly however it was noted that some of these cords were inappropriately placed and out of reach to service users. Cords in service users rooms must therefore be placed at accessible level. High-level minor cracks were noted in most of the bedrooms inspected and in certain cases with wallpaper peeling off. Also all windows must be properly restricted to ensure the safety of service users as evidence was seen of an unsecured window in the top floor bedroom. The fan extractor in the downstairs toilet was dirty and not functioning adequately. The heated towel rail in the bathroom seems to be used as a grab rail for easy access in and out of the bathroom by service users. This was very hot when inspected. The responsible person must ensure that adequate equipment is installed in the bathroom for this purpose. However it was positively noted that all other radiators were appropriately covered. The Shed in the back garden requires urgent attention to either be made safe or disposed as a notice fixed on the shed since November 2004 stated service users should keep away. This therefore restricts service users to use the garden in safety unless appropriate action is taken to secure the shed. Ashleigh Rest Home, DS0000007219.V309476.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 The quality in this outcome area is poor. This judgement had been made using available evidence including a visit to this service. The staffing level is of continued concern. Indication from the inspection shows that the responsible person at times failed to show that resident’s needs are being fully met within the current levels of staffing. EVIDENCE: The staffing level is a concern; this was a requirement from the last inspection, which was not met during this inspection. The home is staffed with a minimum of two care staff throughout the day with one sleep-in and one waking night staff during the night. It was stated by the responsible person that care staff undertake all domestic duties and prepare evening tea as well as preparing all the weekend cooking because the qualified cook only works Monday – Friday. Staff spoken to indicated that this level of work can sometimes be overwhelming as there are service users requiring the assistance of two members of staff. The acting manager stated that nearly 70 of staff have achieved or are working towards achieving either level 2 or 3 in care management. However training should be an on-going process for a staff and recorded in an organised fashion for easy reference. Ashleigh Rest Home, DS0000007219.V309476.R01.S.doc Version 5.2 Page 20 Evidence seen by the inspector from staff personal files indicated that the interview process was not robust. Files inspected did not contain the relevant documentation as required by the Care Homes Regulations 2001. The responsible person must therefore ensure that the interview process is more robust and application form updated to include relevant questions in regards to employment history. Evidence demonstrated that CRB disclosures had not been obtained by the home prior to staff commencing employment. Whilst CRB’s from former employers were available, this does not meet the required Regulations. This must be dealt with as a matter of urgency and will be issued as a requirement in this report. Written references were inadequate and at times falsified as checks made by the inspector confirmed that a care assistant who was not clearly authorised to do so had provided a reference. However an isolated case of good verification practice was noted on file during and after the interview process. Supervision files inspected indicated that recorded level of staff supervision seen did not meet the Minimum Standard required. Evidence showed that in most cases, staff had only received one supervision with some members of staff not receiving any supervision at all for the whole year. Supervision sessions were not detailed and relevant questions relating to professional development were not covered on the forms. The acting manager must therefore ensure that all care staff are supervised at least six times a year; one of which may be the annual appraisal. The responsible person must also review the staffing level ensuring that the acting manager has appropriate allocated management time which should be reflected on the rota in order to carry out her management duties as required. Ashleigh Rest Home, DS0000007219.V309476.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The quality in this outcome area is adequate. This judgement had been made using available evidence including a visit to this service. The home was inspected on all the standards. EVIDENCE: The home is currently running without a registered manager, this was a requirement from the previous inspection, which was not met. It will be repeated again as an urgent requirement in this report. The responsible person was reminded of the requirement to have a registered manager at the home. A senior care worker is presently covering the post as acting manager. The acting manager has a good experience of providing residential care and works well as a team member with the other staff. However the responsible person must ensure that management duties are not neglected and therefore adequate management time for the present acting manager must be allocated and reflected on the rota. Ashleigh Rest Home, DS0000007219.V309476.R01.S.doc Version 5.2 Page 22 The registered person stated that service users finances are managed by relatives apart from one service user whose finances is manager by the responsible person. Service users are given personal allowance as and when required. Records seen by the inspector suggest that the system was robust with all purchases properly accounted for. However, it was suggested by the inspector that only loyalty cards (i.e. “Tesco Club card”) registered to service users should be used when making purchases with their money. The inspector saw evidence that the responsible person visits the home on a regular basis signing the visitor’s book, but there was no evidence of her signing out. This was pointed out as a health and safety issue, which all visitors to the home must observe. However, it was positively noticed on the second day of the inspection that the responsible person signed the visitor’s book appropriately. The record keeping of the home is in need of further and urgent development; information kept was either out of date or not updated. It was noted that service users files are kept in open view and easily accessible. All files must be kept in a secure environment ensuring confidentiality of service users are maintained. It was noticed by the inspector that information relating to a particular service user was missing during the inspection. The responsible person stated this information was with a relative. The responsible person was therefore advised that only copied information is to be given with relevant consent. All records required by Regulation are to be maintained on the premises at all times ensuring that records are updated and maintained in accordance with the Data protection Act 1998. Ashleigh Rest Home, DS0000007219.V309476.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 2 x 1 x 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 2 2 2 x 1 1 2 1 3 STAFFING Standard No Score 27 1 28 1 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 1 3 3 3 1 1 2 Ashleigh Rest Home, DS0000007219.V309476.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 Standard OP1 Regulation 6(a) Requirement The responsible person must ensure that The Statement of Purpose is updated reflecting staffing changes. The responsible person must ensure that the Statement of Purpose reflects the admission procedure. The responsible person must ensure that all service users have their care assessed within 5 days of admission and by people trained to do so. The responsible person must ensure that emergency admission is reflected in the Statement of Purpose. The acting manager must ensure that service users care is appropriately evaluated and clear outcomes recorded. The acting manager must ensure that care plans and risk assessment are updated and implemented to clearly identify service users needs and how those needs are to be met. The responsible person must ensure that there is a policy and DS0000007219.V309476.R01.S.doc Timescale for action 31/10/06 2 OP1 4.3(b) 30/11/06 3 OP3 14.1(a) 20/12/06 4 OP5 14.1 30/11/06 5 OP7 15.2 30/11/06 6 OP8 15.1(b) 20/12/06 7 OP9 12(3) 30/11/06 Ashleigh Rest Home, Version 5.2 Page 25 8 9 OP12 16(2)(n) 21.(2) OP16 10 OP22 23.(2)(o) 11 OP22 23.(2)(c) 12 OP25 23.(2)(b) (p) procedure in place for the receipt, recording and storage of medication, which all staff must adhere to. The acting manager must ensure the development of the activities programme to maximise choice. The responsible person must ensure that the whistle-blowing policy is amended to advise staff of organisation that they can whistle blow to. The responsible person must ensure that shed in the back garden is either made safe or removed. The responsible person must ensure that appropriate grab rail is fitted in the downstairs bathroom. The responsible person must ensure that the following actions are taken: (a) The carpet in room two to either be cleaned thoroughly to remove stains or replaced. (b) Carpet in the hallway entrance to be made safe or replaced. (c) Gaps between the floor and the wall to be sealed in the downstairs toilet (d) Adequate and appropriate lighting are available at all times. (e) Fan extractor cleaned and in working order at all times. The responsible person must ensure that on-going review takes place regarding staffing level to assess if these are sufficient to meet the needs of the service users. DS0000007219.V309476.R01.S.doc 30/11/06 20/12/06 30/11/06 30/11/06 20/12/06 13 OP27 18.(1)(a) 31/01/07 Ashleigh Rest Home, Version 5.2 Page 26 14 OP29 19(c) 15 16 17 OP30 18.(2) 8.(1)(a) 17(3) (b) OP31 OP37 18 OP38 12(1)(b) 19 OP38 23.(d) 20 OP38 13.(4)(c) 21 OP38 12(1)(a) The responsible person must ensure that interview process is robust and references properly validated. The responsible person must ensure that staff are supervised 6 times a year. The responsible person must ensure that a permanent manager is appointed. The responsible person must ensure that records pertaining to service users are kept in the home at all times. The acting manager must ensure that records pertaining to service users health are monitored and recorded regularly. The responsible person must ensure that the home is well maintained with particular attention paid to minor cracks. The responsible person must ensure that food is stored appropriately with opened food labelled with the date of opening. The responsible person must ensure that the fridge/freezer temperature are correctly read and recorded by staff on duty. 31/01/07 31/01/07 31/01/07 30/11/06 30/11/06 31/01/07 30/11/06 30/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP8 Good Practice Recommendations It was recommended that the responsible person purchase a sitting weighing scale. Ashleigh Rest Home, DS0000007219.V309476.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ashleigh Rest Home, DS0000007219.V309476.R01.S.doc Version 5.2 Page 28 - 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!