Inspection on 31/03/08 for Ashlett Dale Rest Home

This inspection was carried out on 31st March 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ashlett Dale Rest Home 05/11/09

Ashlett Dale Rest Home 21/08/06

Ashlett Dale Rest Home 16/11/05

Ashlett Dale Rest Home 04/11/04

Ashlett Dale Rest Home 03/06/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Ashlett Dale Rest Home Stonehills Fawley Southampton Hampshire SO45 1DU Lead Inspector Joy Bingham Unannounced Inspection 31/03/08 09:30 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 Ashlett Dale Rest Home DS0000011884.V359266.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. Ashlett Dale Rest Home DS0000011884.V359266.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashlett Dale Rest Home Address Stonehills Fawley Southampton Hampshire SO45 1DU 023 8089 2075 023 8089 0573 fred.liddington@virgin.net 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) Mr Frederick William Liddington Mrs Maureen Mary Liddington Mrs Collette Willis Care Home 16 Category(ies) of Dementia (0), Mental disorder, excluding registration, with number learning disability or dementia (0), Old age, not of places falling within any other category (0) Ashlett Dale Rest Home DS0000011884.V359266.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) Mental disorder, excluding learning disability or dementia (MD) 2. Old age, not falling within any other category (OP). The maximum number of service users to be accommodated is 16. Date of last inspection 21st August 2006 Brief Description of the Service: At the time of the inspection Ashlett Dale is offering care and support to 14 service users with dementia, learning disabilities, mental illness and physical disabilities, over the age of 65 years. An application has been made to the Commission for the registration of a further 2 single rooms. The home is situated in a semi rural area in Fawley on the outskirts of the New Forest. There is a public house within a short walking distance and a number of other amenities and leisure activities a short car journey away. The home is a two-storey building having a reasonable sized garden in which the residents spend some time during the warmer months. The current fees are between £429 and £450 per week. This information was provided by the registered persons on 7 March 2008. There are additional charges for hairdressing, chiropody, newspapers/magazines, medical requisites, luxury items and toiletries. Ashlett Dale Rest Home DS0000011884.V359266.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 2 star. This means the people who use this service experience good quality outcomes. The site visit was unannounced and took place between 09:30 and 16:30. A full tour of the premises took place, documents and records were examined and staff working practices were observed. Residents, staff and visitors were spoken with in order to obtain their perceptions of the service the home is providing. At the time of the inspection the home was accommodating 14 residents, three male and eleven female, all over 65 years of age. The home’s registered manager was present throughout the visit and was able to provide assistance and information when required. Other matters that contributed to this report included an AQAA (Annual Quality Assurance Assessment) completed by the home and returned survey forms completed by residents and/or their families and staff members. Other information that the Commission for Social Care Inspection (CSCI) had received since the last inspection on 12 August 2006 included statutory notices received about incidents/accidents that had occurred. What the service does well: Ashlett Dale is run by the owners and their daughter who is the registered manager. The home provides the residents with an environment of informality, friendliness and a significant family atmosphere. The residents and their families describe the home as warm, welcoming and kind. We (the commission) are told by the residents that the home’s routines are flexible and they are enabled to make choices about the shape of their day and exercise personal autonomy as far as is reasonably possible. One person, 100 years of age, was spending the day in bed as it was her wish to do so. Residents are positive about the food they receive the care they experience and the range of activities in which they can participate. Ashlett Dale Rest Home DS0000011884.V359266.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Ashlett Dale Rest Home DS0000011884.V359266.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 Ashlett Dale Rest Home DS0000011884.V359266.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, and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All potential residents are assessed prior to moving into the home to determine that their individual needs can be met. People are encouraged where possible to visit the home prior to admission to assess the quality, facilities and suitability of the home. EVIDENCE: The home’s statement of purpose and service user guide is currently being updated as a result of the proposed new bedrooms. They were available at the inspection and relatives confirmed that they knew about the home’s facilities and terms of reference prior to their family entering the home. One relative stated that she lived locally and knew the owners by reputation and also many of the staff. She said the home had a good reputation and she felt very fortunate that her relative had been able to get a place in the home. Ashlett Dale Rest Home DS0000011884.V359266.R01.S.doc Version 5.2 Page 9 A resident said that, ‘with all the knowledge about a place, you never really know what it is like until you move in’ and she ‘was very pleased with being there’. A Care Manager from Social Services told the Commission that in her opinion the assessments the home had made were good. The home manager explained that she undertakes pre-admission assessments on all prospective people, using an assessment tool that covers all the relevant areas necessary to confirm the home can meet the person’s needs. We looked at four pre-admission assessments to confirm this had been done. The information from the assessment contributes to the plan of care drawn up when admission takes place. The files that are established for each resident were sampled and four out of four had contracts established between the resident and the home for the service they receive, detailing the expectations for both parties. The home does not provide intermediate care. Ashlett Dale Rest Home DS0000011884.V359266.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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s health, personal and social care needs are acknowledged and set out in an individual plan of care. They are treated with respect. The home respects privacy, choice and is sensitive to changing needs. EVIDENCE: We looked at the same four plans of care following on from the assessments and told the manager that the four written care plans that were sampled are very basic and limited in their scope. They could be developed and be profiled more significantly as a working document for staff, particularly as care needs increase with dependency levels. Written risk assessments are needed for identifiable hazards seen on the day of the inspection. e.g. moving and handling, non-use of wheelchair foot rests when moving a resident, rugs in bedrooms, a chain blocking access to the foot of the stairs. It is acknowledged, however, that the staff know the residents well, were very familiar with their individual needs and wishes and do not as a routine refer continually to a written care plan. We spoke privately with three of the staff Ashlett Dale Rest Home DS0000011884.V359266.R01.S.doc Version 5.2 Page 11 about the residents and confirmed they were familiar with the individual personalities and preferences for each person. Residents said they felt confidant the home understood what they need and were very satisfied with the care they receive. Comments from people living there include: • it’s wonderful • I really can’t fault it • The owners are lovely • It’s great here • If I asked for the moon they’d try to get it for me • You wont find any problems here. Comments from relatives include: • she’s so fortunate to be there • I know it is a safe place because I know some of the people who work here • She’s really thriving • The hygiene is really good We noted that the care plans had been reviewed each month, dated and signed. The manager told us that all clients have their own personal choice of health care, but the home will advise if needed. We were told of the specific care needs of a former terminally ill resident who had been closely supported by the local hospice, and because of their care the staff had enabled the lady to remain in the home until she died. A book of compliments and positive comments was seen giving ample evidence of relatives’ appreciation of the care the home provides. We walked around the home and noted that people were making use of their own room throughout the day as it suited them. One resident of 100 years had opted for a day in bed and was enabled to do so, with staff popping in frequently to check how she was. Two people entertained visitors in their rooms during the day. One visitor said he was often invited to stay for lunch with his family member but usually declines to do so. A session of physical exercise was taking place in the lounge for about 30 minutes and we noted that all of the residents joined in happily with this, characterised by many smiles and laughter. One resident in an advanced stage of dementia was seated in the lounge with the other people. She was very well cared for in dress, hand and hair care. We noted the staff related to her when they passed by with a gentle touch and close verbal communication that made her respond with smiles. There was a Ashlett Dale Rest Home DS0000011884.V359266.R01.S.doc Version 5.2 Page 12 noticeable absence of anxiety and warm response to contact that spoke well of everyone’s care. We raised a concern about the chain placed at the foot of the stairs as it signalled the fact that people could not use them freely. The manager explained that she had placed this reluctantly as a final measure to discourage another resident, whose room is on the ground floor, from constantly going up and down in the chair lift. Residents with rooms on the first floor reassured us that they were told why it had been placed there, that it was not a discouragement to them, and confirmed they go back to their rooms whenever they wish to. The lunchtime administration of medicines was observed. Only senior staff who have received training and been deemed competent administer medication. Records are kept of drugs received, administered and returned and generally these were completed and up-to-date. However, we drew to the manager’s attention several historic gaps in the records for one resident and she was unable to identify whether the drug had been administered and not recorded, or not administered. Although a carer has been given a lead responsibility for managing the drug procedures the proper recording and regular monitoring of this by the manager has been made a requirement to ensure residents are adequately protected. Antibiotics stored in the domestic fridge were placed in the door of the fridge between the marmite and the milk. They were labelled and dated but could have been confused with something else. The manager was told that they must be kept in a separate lidded container, clearly marked with the name of the resident. Residents told us that they are free to use their rooms whenever they want to and we saw people entertaining their visitors in their rooms. Some rooms were fitted with a personal telephone line. All of the bedrooms were fitted with a lock on the door, lockable personal space and contained personal memorabilia. Each room had a flush toilet and wash hand basin, screened by a curtain. The latter is an unusual feature in residential care. The manager said that most residents say this provision is one of the distinctive positives of the home as people prefer to have a flush toilet in their rooms than having a commode. We checked this with two of the residents and relatives and this view was confirmed. We were told by the staff and the residents that the residents choose how they wish to be addressed. We noted staff speaking and acting respectfully towards each of the residents. Ashlett Dale Rest Home DS0000011884.V359266.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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The routines for daily living and activities are flexible and varied to suit people’s individual needs. Family and friends are able to visit throughout the day. People receive an appealing, balanced diet in pleasant surroundings. EVIDENCE: The routines for daily living and activities are flexible and varied to meet people’s individual needs and wishes. The residents and relatives told us they are able to choose where in the home they spend their time, and when to get up and retire. Many were observed in the lounge and a few remained in their rooms until a time they chose to come downstairs. People told us that they have a choice of meals, deciding the day before on their main meal to help the cook. Comments include: • We get more than enough to eat • The food here is very good • Oh yes, we get plenty-too much really • There’s ample for everyone The menu plan following a 28 day cycle was seen in the kitchen. It was noted that a dedicated cook was employed. Special diets can be catered for Ashlett Dale Rest Home DS0000011884.V359266.R01.S.doc Version 5.2 Page 14 (currently a diabetic diet). The serving of lunch was observed. Ample portions were provided with acknowledgement of personal preferences. Two meals were pureed. We advised that, where possible, vegetables and meat should be pureed separately to guarantee colour interest and taste. The manager told us that one resident would not eat anything unless it was in a soup format. Due to his advanced confusion it was not possible to verify this with the person concerned. We observed the feeding of a very frail lady. In the main the staff followed best practice, 1:1 with ample time given and prompting when concentration was poor, without pressure. However, staff blowing on mouthfuls to cool the food is poor practice and this was drawn to the manager’s attention for correction. The home stated within their annual quality assurance assessment that they provide a daily therapist, outings, live music, barbeques, and church communion (from different denominations). Residents said they are happy with the ’programme’, and drew attention to the pleasant garden where the lounge overlooks. They spoke of walks out with the staff they were looking forward to when the weather is better. We noted that there was significant communication between the residents, looking out for each other, commenting on how they were and reassuring hand touches. Ashlett Dale Rest Home DS0000011884.V359266.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People and their relatives are aware of how to complain. Procedures are in place to protect people from abuse. EVIDENCE: The home’s complaints procedure is included in the service user guide and is provided in each bedroom. The annual quality assurance assessment states there have been no complaints but the home is always open to suggestions of better ways to do things. It states that he home does not handle any personal finances for residents. This is carried out by families or an advocate. Residents and relatives told us that they felt they could raise any issue with the staff, manager or owners and that this would be addressed, but didn’t feel they needed to. Comment from a resident: • I’ve got no complaints at all Comment from a visitor: • She likes it here and I think it’s great The home has a complaints and a compliments file. Ashlett Dale Rest Home DS0000011884.V359266.R01.S.doc Version 5.2 Page 16 The home has a policy and procedure on safeguarding from abuse. When asked about this staff evidenced appropriate understanding of what to do if abuse was suspected, and saw themselves as key advocates for all of the residents. One member of staff said she had previously involved the CSCI in a whistle blowing incident in another home where she had worked and would not hesitate to take action if there was any reason to be concerned. One weak area in the homes protection procedures is covered under the staffing section of the report. Recruitment checks must be tightened up by the home in order to provide comprehensive protection for residents. Ashlett Dale Rest Home DS0000011884.V359266.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is generally well maintained both internally and externally, providing a safe, comfortable and clean environment. EVIDENCE: We looked around the home during the course of the day. Most of the bedrooms and all communal areas, including the kitchen, bathrooms and laundry were seen. Overall the home was clean and well maintained. It was free from adverse odours. The home employs domestic staff who were seen cleaning the rooms during the inspection visit. People living there and visitors said the home is always kept clean. The home has a large lounge that overlooks the attractive rear garden. Chairs are arranged around the walls according to the residents’ choice. There is a separate dining room arranged with small tables seating four people with space for people who may use a wheelchair. People can choose a number of places to sit and socialise or they may spend time in their rooms. Ashlett Dale Rest Home DS0000011884.V359266.R01.S.doc Version 5.2 Page 18 All the bedrooms are single and fitted with a wash hand basin, flush toilet, and a curtain screen. As well as the required furniture some have televisions. The floors have a hospital-style washable surface, softened with large rugs to make them warmer in appearance. However, while not wanting to change this, we said that they could be hazardous for elderly persons with limited walking ability. Risk assessments should be completed for each vulnerable person. Bathrooms are appropriately equipped and well positioned. The home has been recently inspected by environmental health and the fire service because of the proposal to increase in numbers. A separate laundry is provided, equipped with commercial machines. Washing machines have the specified programming ability to meet disinfection standards. There is a procedure for control of infection, provision of protective clothing and hand washing. The quality assurance return from the home confirmed that all staff are trained in infection control. Ashlett Dale Rest Home DS0000011884.V359266.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home employs appropriate numbers of care and ancillary staff to ensure that people’s needs are met. The staff are competent and caring. The pattern of recruitment is generally acceptable but procedures need to be tightened to ensure the full protection of residents. EVIDENCE: Survey returns from people who live in the home and their relatives were positive about both the kindness and competence of the care staff. One relative commented that residents are well cared for by staff ‘who are patient and caring, they are given choices in their care and are treated with respect, there is a real family atmosphere.’ Another said ‘they always have time for us even if they are really busy’. The written staff rota was seen and it corresponded with those on duty. On the day of the inspection there were two carers on duty, plus a cook, a therapist and a cleaner. This was in addition to the manager and two owners who were both present. When asked what the home was like to work in and whether the staff had any improvements to suggest, the matter of adequate numbers of staff on duty did not feature as an issue. Staff scored the sense of staff morale between 8 and 9 out of a possible score of 10. Ashlett Dale Rest Home DS0000011884.V359266.R01.S.doc Version 5.2 Page 20 According to the AQAA the home employs 13 permanent care staff. Five of the staff have NVQ level 2 and 6 are in process of working towards this. The manager is an internal assessor for NVQ, having obtained the relevant City and Guilds certificates. Agency staff are engaged to complete shifts at times. At least 10 staff have left employment in the home in the last 12 months. The manager said the turnover of staff, with pressures of constantly training new staff is the single greatest difficulty the home faces. Staff records were sampled. Four files were inspected. Most were in order providing CVs, written references, CRB and POVA checks, contracts, ID, photographs etc. However one file lacked any references, yet the applicant had been taken on and had started work. She had proved to be a reliable member of staff. The potential risk posed to residents by engaging someone without references, particularly from a previous care employer, is unacceptable and this was drawn to the manager’s attention. Information in the home’s AQAA said that all new staff attend for a 2 hour induction and then start by shadowing an experienced member of staff. All mandatory training is carried out in-house and is completed within the first few weeks of employment. Staff confirmed they would not be asked to undertake tasks outside the level of their knowledge or skill. Staff records were seen and sampled. Training is largely provided by a reputable private consultancy. We noted that 5 staff were booked on training starting in April. The staff on duty confirmed that they receive periodic supervision, annual appraisal, and engage in staff meetings normally held every three months. Ashlett Dale Rest Home DS0000011884.V359266.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The providers and manager have the necessary skills and experience to ensure that the home is appropriately managed and run in the best interests of the people who live there. People’s financial interests are safeguarded. The health, safety and wellbeing of staff and residents are promoted. EVIDENCE: Collette Willis, registered manager is full time and has worked at Ashlett Dale since 1983. She is an experienced carer and is an internal assessor for NVQ (national vocational qualification). She has obtained the Registered Manager’s Award (RMA) and is in process of completing the final module of NVQ Level 4. The manager routinely engages with the training as it is provided to her staff. One of her training aims is to gain confidence with IT and computer skills. Ashlett Dale Rest Home DS0000011884.V359266.R01.S.doc Version 5.2 Page 22 The staff and residents were all aware who is the registered manager and felt the support and accessibility of the owners was a positive feature in the home. Each staff member spoken with said they felt able to raise any issues of concern at handover, staff meetings, or supervision. They said that the open, ‘family’ culture of the home meant they did not wait for formal opportunities for discussion but dealt with things informally as they arose. The manager said that normally the home invites comments about the service by survey in January from residents, their families and stakeholders. Due to the uncertain timing for personal medical needs this activity has been postponed this year. In relation to finances the home does not handle any personal monies on behalf of the residents. An inventory is established and maintained of items brought into the home by the residents. The manager tries to ensure the safe working practices by planning courses on health and safety within Ashlett Dale, including first aid, adult protection, manual handling, food hygiene, fire and medication. Limited risk assessments are in place. The AQAA detailed recent reviews and updates on servicing contracts for electrical and fire equipment, lifts and hoists, heating and gas appliances. Ashlett Dale Rest Home DS0000011884.V359266.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 X X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 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 3 X 3 x 3 X X 3 Ashlett Dale Rest Home DS0000011884.V359266.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation Requirement Timescale for action 01/06/08 2 OP9 3 OP29 13 (4) (c ) The home must identify all risks to the health and safety of individual service users and as far as is reasonably possible, eliminate them. These should be recorded in the care plan. 13 (2) When medication is administered 01/06/08 it must be clearly recorded each time, to ensure that people receive the correct levels of medication. 19 (1) (b) The home must obtain two 01/06/08 written references for any person employed to work at the care home to ensure service users are protected. 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 Ashlett Dale Rest Home DS0000011884.V359266.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Ashlett Dale Rest Home DS0000011884.V359266.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. 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