Inspection on 13/10/05 for Ashley Court

This inspection was carried out on 13th October 2005.

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

Ashley Court 07/06/07

Ashley Court 04/07/06

Ashley Court 12/05/05

Ashley Court 14/10/04

Ashley Court 15/06/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Ashley Court Ashley Court 251 Penn Road Penn Wolverhampton West Midlands WV4 5SF Lead Inspector Bhag Jassal 13 th Announced Inspection October 2005 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 Ashley Court DS0000058006.V257974.R01.S.doc Version 5.0 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. Ashley Court DS0000058006.V257974.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ashley Court Address Ashley Court 251 Penn Road Penn Wolverhampton West Midlands WV4 5SF 01902 335584 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) Ashley Court Care Ltd Narinder Kaur Bachra Care Home 18 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (18), of places Physical disability over 65 years of age (5) Ashley Court DS0000058006.V257974.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Service Users with a physical disability may only be admitted to rooms 5, 7, 9, 12 and 15. No more than 5 service users may be admitted having a physical disability (PD). No more than 6 service users may be admitted having mild dementia (DE). Bedroom 1, once vacated by the current service user is to be converted into a `multipurpose` room. At this time the Commission must be informed and a new certificate will be issued reducing the registered beds from 18 to 17. Adequate staffing levels must be maintained to reflect the increase in registered numbers and the change in categories of clients accommodated. 12th May 2005 5. Date of last inspection Brief Description of the Service: Ashley Court care home is providing personal care and accommodation for eighteen older people. The home is located on the Penn Road, one and half miles from Wolverhampton city centre. It is close to the local shops and amenities. The home is a large semi-detached property that was adapted as a residential care home in 1981; and further extension and improvements have been made over the years. The accommodation consists of single occupancy rooms with en-suite facilities, communal sitting areas and dining room. There are gardens and a patio area at the rear of the building. There is ample car parking space at the front of the building. Ashley Court DS0000058006.V257974.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and started at 9.00 am and lasted eight hours and forty minutes. All 18 places were occupied. The inspection included discussions with the Registered Provider/Manager, staff, service users and their relatives/friends. The daily routines were observed and service users and staff records, policies and procedures were examined. Inspection of premises both inside and outside and facilities were also undertaken. Discussion also took place with the Registered Provider/Manager regarding the progress made by the home in implementing the requirements contained in the previous inspection report dated 12 May 2005. The Registered Provider/Manager stated that she has moved the currently occupying service user from bedroom 1 to another bedroom in the home. She has placed another new service user in bedroom 1. This has taken place without informing the Commission for Social Care Inspection prior to new admission. This is a condition of registration, which the Registered Provider appeared to be have overlooked. The service user in question must be placed again in bedroom 1 and must comply with the condition of registration at all times. It was also noted that the premises are being extended to include further three bedrooms with en-suite facilities, small lounge, bathroom/WC, visitors’ room, hairdressing salon, medical/treatment room and linen store. The existing dining room is also to be extended to increase dining space. What the service does well: The home is currently registered for 18 older people, of which five with Physical Disability and six with mild Dementia care needs. The home makes every effort to provide individuals with good standard of care to meet assessed needs following a care plan. The home has a good key worker and staff supervision system in place. The home communicates well with families, friends and representatives of the service users. The visitors’ book indicated a lot of activities. The service users spoken with said that they are happy and enjoy living in a homely and caring place. The service users were in the lounges engaging in their daily activities. They further stated that they were comfortable and satisfied with the care Ashley Court DS0000058006.V257974.R01.S.doc Version 5.0 Page 6 provide. This was confirmed by their completed questionnaires received by the Inspector. The completed questionnaires received back from the service users’ relatives also indicated their satisfaction with the care and facilities offered at Ashley Court. There were three people who indicated that there are not enough numbers of staff on duty at all times, but others commented positively. The atmosphere within the home was observed to be relaxed, comfortable and friendly. The friendly rapport was observed between service users and staff. Meals are varied, well balanced and presented to meet the each individual’s choices, preferences and requirements. The home provides a satisfactory standard of accommodation, which is being maintained to good standard. What has improved since the last inspection? The home has continued to make improvements in care practices and recording formats. The home has provided training in safe handling of medication to four carers, who are responsible for handling of medication. The NVQ Level 2/3 and safe working practice topics training programme is being implemented. The home has also implemented an activities programme for service users. All members of staff have been CRB and POVA checked, and two written references are obtained on all new staff before they are appointed. The home has continued to redecorate bedrooms and where needed carpets have been replaced and/or professionally cleaned. All the requirements and recommendations contained in the recent inspection reports of the Fire Safety Officer and the Environmental Health Officer have been appropriately implemented. New dishwasher has been provided in the kitchen, and a loop system has been installed in the home for the benefit of service users. The Registered Provider is now also the Registered Manager at Ashley Court, and she has already made a few changes in order to improve care practices, key worker staff supervision arrangements. Ashley Court DS0000058006.V257974.R01.S.doc Version 5.0 Page 7 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. Ashley Court DS0000058006.V257974.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashley Court DS0000058006.V257974.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4 and 6 The service users are assessed before moving into the home. They are provided with the opportunity to visit the home to assess the quality, facilities and suitability of the home before their relatives moves in. Service users receive written statement of the terms and conditions of residency. EVIDENCE: A sample of three service users’ care plans and files were examined at the inspection. All contained evidence that the service users received the benefit of a comprehensive assessment prior to admission. The Registered Manager also carryout the assessments and these details are documented on care plans, which are drawn up by senior staff with the help from the service users and their relatives, and where appropriate other professionals. It was evidenced that all service users have been provided with contracts/the statement of the terms and conditions of residency. The home has a good admission procedure, which is made available to all prospective service users and their relatives and/or representatives. The Ashley Court DS0000058006.V257974.R01.S.doc Version 5.0 Page 10 service users and/or their relatives can visit the home and if they indicate to the home of their choice, then the home formally inform them if it can meet the needs of the prospective service users. The home does not offer an intermediate care service. Ashley Court DS0000058006.V257974.R01.S.doc Version 5.0 Page 11 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 and 10 The staff within the home is aware and sensitive of the needs of each and all service users and meet their needs in a professional manner. There is clear and consistent care planning system in place, which provides the information the staff requires to meet the service users’ health and care needs. EVIDENCE: It was evidenced that all service users undergo a comprehensive assessment of their needs prior to admission to the home. A care plan is produced, which is based on the assessment of needs. The home operates a key worker system, which helps to ensure that the recommendations arising from the care plans and monthly reviews are implemented. Three service users’ care plans were examined in detail and it was noted that the short–term and long–term goals and appropriate interventions required to put them into action to meet the individual service user’s needs are identified. It was also evidenced that the care plans are reviewed on a monthly basis. The daily care recording formats were also examined and it was noted that the quality and details of recording has steadily improved. The Registered Manager stated that the staff Ashley Court DS0000058006.V257974.R01.S.doc Version 5.0 Page 12 would be asked to continue to make further improvements in daily care (both day and night) recordings. The home also ensures that nutritional screening is being undertaken, including weight gain and loss records are maintained and appropriate action is taken if required. The home also maintained records of all health checks. Case tracking demonstrated an effective review process together with the home’s ability to meet the changing needs as they occur. The service users’ health is closely monitored and appropriate medical care services are sought as and when required. It was observed on the day of inspection that no personal care interventions were taken in communal areas. In addition, consultation with health and social care professionals are carried out in the service users’ bedrooms. The Inspector spoke to at some length with several service users and all of them commented positively about their care and they felt that they have been provided with everything they need. The service users generally felt that the home is comfortable, warm and kept neat and tidy. It was evidenced from the staff training records that four senior carers who are responsible for administering medication and safe handling of medicines have completed their training in safe handling of medication. The Registered Manager stated that six carers are enrolled through the Distance Learning/work place learning mode of training and they will complete by end of February 2006 and three new carers are to be enrolled to undertake this mode of training shortly. Ashley Court DS0000058006.V257974.R01.S.doc Version 5.0 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 and 15 Ashley Court provides a good quality of care and promotes lifestyles for the service users in residence. The service users maintain contacts where they wish with the family, friends and the local community. The service users are positively helped to exercise choice and control over their lives as far as possible. Meals at Ashley Court are of a good homely type offering both choice and variety and catering for special needs. EVIDENCE: It was evidenced that the home provides an activities programme in accordance with the service users’ choices, preferences and capacities in relation to – social and leisure activities and cultural interests. It was noted that the home also organise entertainment delivered by external entertainers. The records of activities enjoyed by the service users are being appropriately maintained. All the service users spoken to stated that they are in touch regularly with their friends and family members. They also spoke about their visitors’ involvement and interest in their daily care matters. The visitors’ book in the home showed a considerable activity. The relatives of three service users stated that they visit the home at various times of the day as they wish. All relatives who spoke to the Inspector said they are given warm and friendly welcome by the Ashley Court DS0000058006.V257974.R01.S.doc Version 5.0 Page 14 staff whenever they visit. The service users also keep contacts with the local community – for example, church services, shops, park and pubs. The Registered Manager stated that the service users are positively assisted and helped to exercise choice and control over their lives. A close liaison is maintained with the relatives and representatives where the service users are not able to make certain decisions. The service users and their relatives are informed about the availability of the local advocacy service based at the local Age Concern office. It was evidenced that the home provided a varied, wholesome and nutritious diet. The meals provided during lunchtime on the day of inspection were well received by the service users. The Registered Manager stated that the menu is changed on a regular basis and in consultation with the service users. Several service users told the Inspector that the food was very nice, tasty and well prepared. Several other service users stated that the food was very good and offering a good variety. The cook is well trained in food safety and hygiene matters. The kitchen is well equipped and kept clean and tidy. There was adequate food stocked in the home. Ashley Court DS0000058006.V257974.R01.S.doc Version 5.0 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 and 18 Concerns and complaints are dealt with promptly and professionally. The service users’ legal rights are protected appropriately. The service users are protected from abuse by the home’s policies and procedures. The arrangements for the protection of service users from abuse are satisfactory. EVIDENCE: The home has a good Complaints Procedure, which is referred to for information in the home’s Service Users’ Guide and in the Statement of Purpose for the home. There is a system of recording concerns and complaints. It was noted that there have been no complaints directed to the Commission for Social Care (CSCI). Several service users told the Inspector that their views and concerns are always listened to by the Registered Manager and the senior carers. The Registered Manager stated that as far as possible the service users’ legal rights are protected appropriated and they are positively assisted to take part in elections. The home has a policy and procedure in place with regard to protection of service users from all forms of abuse. The Registered Manager stated that all members of staff have been made aware of the adult abuse and protection issues through induction training and supervision arrangements. The Registered Manger stated that all staff would receive formal training in adult protection from abuse shortly. Ashley Court DS0000058006.V257974.R01.S.doc Version 5.0 Page 16 Ashley Court DS0000058006.V257974.R01.S.doc Version 5.0 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, 21, 22, 24, 25, and 26 The general standard of environment is good providing service users with a homely place to live. The standard of cleanliness reflects the ongoing cleaning schedule, which maintains this standard throughout the home. EVIDENCE: The home offers a comfortable and well-maintained environment to all service users. The home has ample space for dining and lounge areas. All recommendations contained in the recent inspection reports of the Fire Safety Officer and the Environmental Health Officer has been implemented appropriately. It was noted that the Registered Provider has installed a CCTV monitoring system, which covers main entrance from Penn Road, car park and patio areas at the rear of the premises. The CCTV monitoring system also covers areas inside the home – for example, the main entrance reception/hall area and from dining room to the rear corridor, of which there are three bedrooms, bathroom and kitchen. This latter areas covered by the CCTV monitoring system is not Ashley Court DS0000058006.V257974.R01.S.doc Version 5.0 Page 18 acceptable, which is considered to intrude on the daily life of service users accommodated in this part of the home. The staff during their meetings with the Inspector also expressed their concern about possible invasion of the privacy and dignity of the service users. The Registered Provider must take appropriate action to remove the CCTV monitoring system, which covers the rear corridor in order to preserve the privacy and dignity of the service users. A new dishwasher and an extractor fan have been provided in the kitchen. However, extractor fans in several en-suite facilities in bedrooms must be repaired and maintained in working order at all times. The home has undertaken a risk assessment of the premises and facilities by a suitably qualified occupational therapist. A suitable loop system also has been provided in the home for the appropriate use of service users. There are adequate number of bathrooms/showers and WCs in the home. There is satisfactory standard of furniture, fittings and equipment in the service users’ bedrooms. It was noted that many of the bedrooms have been “personalised” by the service users. However, the Registered Manager must ensure that new carpet/suitable floor covering is provided in bedroom 15; and that the portable electrical heater is removed immediately from bedroom 3 in the interest of the safety of the service user; and the self-closure mechanisms on several bedroom doors must be checked more regularly to ensure that these actually closes to their rebate; and that overhead lights in several bedrooms were out of order and these must be maintained in working order at all times for the use of the residents. The fused light bulbs in the dining room and the main lounge are replaced. Net curtains must be provided in the bedrooms on the ground floor in the interest of privacy of the service users. It was noted that there were no hot water supply in bedrooms 5, 6 and 15; and the hot temperature in several bedrooms varied from 33 degrees C to 55 degrees C and 29 degrees C in the bathroom/shower on the first floor. This is not acceptable in any circumstances. This also poses serious health and safety matter for the service users and staff in the home. The Registered Manager took immediate action to make arrangements for the plumber to come to the care home and rectify this deficiency in the heating/hot water system. The Registered Provider/Manager must ensure that the hot water temperature in all the hot water outlets throughout the care home must be maintained at the required temperature level of close to 43 degrees C at all times and properly tested on a weekly basis and if the test showed any deficiency in the hot water/heating system then appropriate action must be taken to rectify the problem and all records maintained. Suitable tables in several bedrooms still to be provided for the use of residents. The Registered Manager stated that suitable locks for the bedrooms have been purchased and are now to be fitted as a rolling programme and to be completed by the end of November 2005. Ashley Court DS0000058006.V257974.R01.S.doc Version 5.0 Page 19 During the inspection, the home was generally found to be clean, tidy and free from any unpleasant odour. The home has good policies and procedures in place regarding infection control. The Registered Manager stated that all staff has received induction training in infection control and they are made aware of the dangers of cross-infection. The Registered Manager must ensure that all members of staff receive formal training in infection control as a matter of priority. Ashley Court DS0000058006.V257974.R01.S.doc Version 5.0 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 29 The home is not adequately staffed, which could have impact on the quality of care and the ability of the home to meet the needs of 18 service users, six of whom are with dementia care needs. The home continues to support staff to complete training. The home has good staff recruitment policies and procedures in place. EVIDENCE: The information provided by the Registered Manager and the available staff rotas showed that the home at present is not adequately staffed to care for 18 service users. The home currently provides two carers and a senior carer on duty throughout the day and two night carers on wakeful duty and a senior carer/manager on call, and a cleaner for five days and cook cover for seven days a week. The carers are expected to cover laundry duties and evening teatime catering duties and domestic duties at the weekends. The above staffing levels are minimum to meet the varying and differing needs of 18 service users, including six service users with dementia care needs. The Registered Manger’s hours are in addition to the above and considered to be supernumerary to allow herself to manage the home effectively and efficiently. It should also be noted that the Registered Manager is also the Registered Provider and thus she has to devote time to carryout her role as the Registered Provider as well. Ashley Court DS0000058006.V257974.R01.S.doc Version 5.0 Page 21 The Registered Provider/Manager must ensure there is adequate catering staff cover for evening teatime and laundry assistant duties during the whole week and domestic assistant cover at the weekends as a matter of priority. It was evidenced from the staff training records that four carers have completed their NVQ Level 2 training and three carers are currently undertaking this mode of training. The Registered Manager stated that the remaining members of staff would be enrolled to receive this mode of training shortly. The Registered Manager stated that now all new members of staff receive the TOPSS Induction and Foundation training. The home has a staff training programme in place, which is now being implemented. The Registered Manager stated that a number of staff members are undertaking their training in safe working practice topics (i.e. moving and handling, food hygiene, firstaid, health and safety and infection control). However, those members of staff who as yet not received this mode of training must do so as a matter of priority. Similarly those members of staff who as yet not received training in dementia care, management of challenging behaviours and adult protection from abuse should complete this training as soon as possible and as a matter of good practice. Discussion with the Registered Manager and examination of the most recently recruited members of staff files demonstrated that thorough recruitment procedures had been followed in line with the home’s recruitment policy. Two written references and Enhanced CRB and POVA checks are being obtained before new member of staff are appointed. The Registered Manager is very aware that any member of staff with criminal records would not be employed in accordance with the Department of Health Guidance issued in July 2004. Ashley Court DS0000058006.V257974.R01.S.doc Version 5.0 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 The home is managed by an experienced Registered Manager, who lead a staff group with a great deal of confidence. The Staff is clear of their roles and responsibilities. Good systems of communication are in place to seek views of service users and their families and friends. Money is well managed on behalf of the service users by the Registered Manager. The staff is regularly supervised to enable them to carryout their work professionally. Health, safety and welfare of service users and staff are promoted by safe working systems put in place by the Registered Provider/Manager. EVIDENCE: Mrs Narinder Bachra – the Registered Provider, who is also the Registered Manager. Mrs. Bachra was registered to be the Registered Manager in August 2005. She is currently undertaking her NVQ Level 4 in management and care Ashley Court DS0000058006.V257974.R01.S.doc Version 5.0 Page 23 qualification training and she is to complete this required qualification training by the end of March 2006. The Registered Manager stated that she as yet have not implemented fully Quality Assurance monitoring system in the home. She has developed a quality assurance monitoring system through which the views and comments of the service users, their relatives other stakeholders and the staff have been sought. Mrs. Bachra stated that she would implement fully the National Minimum Standard OP33 and the home’s Quality Assurance development plan by the end of December 2005 as a matter of priority. A report of analysis of the feedback received through the questionnaires also to be completed by the end of December 2005 Monies held at the home on behalf of the service users are handled in line with the home’s policy and procedure of handling service users’ money. A sample of three service users’ money was checked and found to be satisfactory at the time of the inspection. The Registered Manager stated that not all members of staff received their required numbers of formal supervision meetings since the last inspection. Mrs. Bachra stated that the deputy manager would be assisting her in completing this task. Accidents and fire prevention records and procedures were examined in some detail, which were being appropriately maintained. Matters pertaining to fire safety and environmental health were also found to be satisfactory and all issues have been appropriately addressed. The Registered Manager stated that the staff is still undertaking their safe working practice topics training courses and this is an ongoing training programme. All new members of staff would also receive this mode of training as a matter of priority. (See NMS 30 above). Ashley Court DS0000058006.V257974.R01.S.doc Version 5.0 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 18 3 2 X 2 3 X 2 2 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 3 Ashley Court DS0000058006.V257974.R01.S.doc Version 5.0 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP19 Regulation 12 & 23 Requirement The Registered Provider must take appropriate action to remove the CCTV monitoring system, which covers the rear corridor area inside the premises in order to preserve the privacy and dignity of the service users. The Registered Provider must ensure that the extractor fans in several en-suite facilities in bedrooms must be repaired/replaced and maintained in working order at all times. The Registered Provider must ensure that new carpet/or suitable floor covering is provided in bedroom 15; and that the portable electrical heater is removed from bedroom 3; and that the self-closure mechanisms on several doors must be checked regularly to ensure that these actually closes to their rebate; and that the overhead lights in several bedrooms were out of order and must be maintained in working order at all times and he fused light bulbs in the dining room DS0000058006.V257974.R01.S.doc Timescale for action 31/12/05 2 OP21 23 31/10/05 3 OP24 12, 13 & 23 31/12/05 Ashley Court Version 5.0 Page 26 4 OP25 13 &23 5 OP27 18 6 OP28 18 7 OP30 12 & 18 8 OP31 9 and in the main lounge are replaced; and that net curtains are provided in the bedrooms on the ground floor in the interest of preserving the privacy and dignity of the service users; and suitable locks be fitted on the bedroom doors; and that suitable tables to sit at are provided in several bedrooms. The Registered Provider must ensure that the hot water temperature in all the hot water outlets in maintained at the required level of close to 43 Degrees C at all times and thorough weekly tests are carried out and any defects identified must be rectified immediately in the interest of safety of the service users and staff. The Registered Provider must take appropriate action to ensure that there is adequate staff cover by a cook for evening teatimes daily, and domestic duty cover at the weekends, and laundry assistant cover on daily basis, in order to ensure that the carers actually cover caring duties for the residents. The Registered Provider must ensure that all those members of staff who as yet not received their NVQ Level 2 qualification training must do so as a matter of priority. The Registered Provider must ensure that all those members of staff who as yet not received their training in safe working practice topics must do so as a matter of priority. The Registered Manager must complete her NVQ Level 4 in management and care qualification training by DS0000058006.V257974.R01.S.doc 14/10/05 31/10/05 31/03/06 31/03/06 31/03/06 Ashley Court Version 5.0 Page 27 9 OP33 24 10 OP36 18 31/03/06 The Registered Provider must 31/01/06 ensure that the home’s annual quality assurance development plan is fully implemented and ensure outcomes for service users; and feedback obtained on the services and facilities provided by Ashley Court through suitable questionnaires or other formats from the service users and their relatives and other stakeholders must be analysed and a report made available in the home and to the CSCI for inspection. The Registered manager must 31/12/05 ensure that All members of staff receive their formal supervision meetings at the required intervals (i.e. six times a year). 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 OP30 Good Practice Recommendations The Registered Provider should consider providing specialist staff training in protection from all forms of abuse, management of challenging behaviours, dementia care and disability awareness as a matter of good practice. Ashley Court DS0000058006.V257974.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Wolverhampton Area Office 2nd Floor St. Davids Court Union Street Wolverhampton WV1 3JE 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. 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