Inspection on 07/06/07 for Ashley Court

This inspection was carried out on 7th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 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

Ashley Court 04/07/06

Ashley Court 13/10/05

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 Unannounced Inspection 7th June 2007 09:15 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.V342135.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. Ashley Court DS0000058006.V342135.R01.S.doc Version 5.2 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) www.ashleycourtcare.co.uk Ashley Court Care Ltd Narinder Kaur Bachra Care Home 21 Category(ies) of Dementia - over 65 years of age (9), Old age, registration, with number not falling within any other category (21) of places Ashley Court DS0000058006.V342135.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home can provide care and accommodate for 21 service users in the category (OP), of these 9 places can be for service users with dementia care needs DE (E). The home can accommodate service users aged 60 years on admission whose needs can be met as specified in the Statement of Purpose. 4th July 2006 Date of last inspection Brief Description of the Service: Ashley Court care home is providing personal care and accommodation for 21 older people and 9 of these people can be with Dementia care needs. 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 21single 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. The present Responsible Individual/Registered Manager Mrs Narinder Kaur Bachra (on behalf of Ashley Court Care Ltd) has been operating this service since February 2004. Ashley Court Care Ltd makes their services known to prospective service users in The Statement of Purpose and Service Users’ Guide. The inspection report is mentioned in the statement of purpose and how a copy can be obtained. The care home rates are reviewed annually and service users are notified one month in advance. The only additional charges to service users are for hairdressing and chiropody. This is clearly laid out in the terms and conditions. Fees for Ashley Court as of 1st April 2007 are: £347.00 to £398.00. All service users pay monthly. Ashley Court DS0000058006.V342135.R01.S.doc Version 5.2 Page 5 Ashley Court DS0000058006.V342135.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This report is on a Key Inspection, part of which included an unannounced visit undertaken on 7th June 2007. This unannounced visit started at 9.15 am and lasted 8 hours and 55 minutes. The home had 18 places occupied and three remain vacant. The judgements made within this report are based upon information supplied by the home, from interviews with staff, people who use the service and their relatives. During the course of inspection the assessment information and care plans were case tracked for 6 people who use the service. Medication administration was checked. Staff records were seen to check staff rotas, recruitment procedures and training. Various documents were seen in order to check compliance with health and safety legislation. A tour of premises was also undertaken and observations of care practices and interaction between staff and people who use the service was also completed. Discussions took place with several members of staff and 10 people using the service were spoken to throughout the day of inspection. The Registered Manager – Mrs Narinder Bachra was present throughout the inspection process. All the information received from the care home was considered and discussed with Mrs Bachra. What the service does well: The home makes every effort to provide individuals with a good care to meet the assessed needs following a care plan. The home has a good key worker and staff supervision system in place. The home communicates well with the families, friends and representatives of people using the service and welcomes visitors. People who use the service say they are happy and content with living in a homely and caring place. The home provides a relaxed, comfortable and friendly atmosphere where people are treated with respect and dignified way. People using the service are often vulnerable both physical and emotionally and the Care Manager/Owner – Mrs Bachra ensures that staff are recruited with the ability to carryout personal services for people sensitively and Ashley Court DS0000058006.V342135.R01.S.doc Version 5.2 Page 7 tactfully. The recruitment of good caring staff is critical to the running of care homes and the Care Manager/Owner at Ashley Court undertakes this carefully. The home has a good training programme in place. A majority of staff have received mandatory training in safe working practice topics, dementia care, adult protection, safe handling of medication and equality and diversity. Thus, this training will ensure that they have improved their knowledge and skills to meet the changing needs of people who use the service. The home provides good standard of accommodation and facilities. What has improved since the last inspection? Two requirements and one recommendation made at the previous inspection had been fully addressed. The Care Manager has gained the required qualifications and competent to manage the care home. Through conversation she demonstrated she works continuously to improve services and provide an increased quality of life for people using the service. The Care Manager is very service user focused, leads and supports an enhanced staff team providing them with improved training and supervision. This style and approach to management aims to pursue future improvements in all aspects of the service. The home has made good improvements in their record keeping and care planning. Care plans seen for people using the service were informative and gave some indication of how care is to be delivered for each of them. Medication practices have improved and more staff have received training in safe handling of medication. Majority of staff have completed their training in Dementia care and that will enable them to expand their knowledge and skills and enhance the care they give to people using the service. It was noticeable that there have been many improvements made to the environment of the home along with the recently completed extension works to the premises. A rolling programme of decoration has been implemented, and communal areas have been redecorated and new floor covering and items of furniture have been provided. The garden and patio areas at the rear and car park at the front of the premises have been improved and made accessible and secure. Ashley Court DS0000058006.V342135.R01.S.doc Version 5.2 Page 8 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. Ashley Court DS0000058006.V342135.R01.S.doc Version 5.2 Page 9 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.V342135.R01.S.doc Version 5.2 Page 10 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): 3 and 6. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Ashley Court provides detailed and clear information to people who will be using the service and their families to enable them to make decisions about whether or not to live at the home. Everyone receives full needs assessment prior to admission to the home to make sure that their needs can be met. EVIDENCE: Admissions are not made to the home until a full assessment has been undertaken. The home is then able to confirm that they can meet the needs of the individual through the service they deliver as detailed in the Statement of Purpose. For people who are self-funding and without a care management assessment, they always receive assessment by the Care Manager. Six files/care plans of people who use the service were inspected, which contained Ashley Court DS0000058006.V342135.R01.S.doc Version 5.2 Page 11 pre-admission assessments of their needs, both from assessments by the home’s senior staff and other relevant professionals. Observations and discussions with people using the service, their visiting relatives, the Care Manager, staff on duty indicated that the home continues to meet the needs of older people and those with Dementia care needs in a satisfactory and sensitive manner. It was noted from the staff training records that all members of staff with the exception of one member of staff have received training in Dementia care. Ashley Court DS0000058006.V342135.R01.S.doc Version 5.2 Page 12 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. Everyone who use the service have individual plans of care, which ensures that their personal, healthcare and social needs can be met. Medication is administered and stored in a manner that safeguards everyone using the service. People using the service are treated with respect and dignity and their right to privacy is understood and upheld. EVIDENCE: Everyone using the service undergo an assessment of their needs prior to admission to the care home. A care plan is produced, which is based on the assessment of needs. The home operates a good key worker system, which helps to ensure that the recommendations arising from the care plan reviews are implemented. Six care plans of people using the service were case tracked and examined in detail. There was evidence to show that the short-term goals and long-term goals, aims and objectives were clearly identified and Ashley Court DS0000058006.V342135.R01.S.doc Version 5.2 Page 13 appropriate interventions required to put into action to meet the individual needs of people using the service were also clearly identified. Discussions with people who use the service showed that the home has a strong ethos of involving them in all aspects of their life. The care plans that were read were clearly written and included an element of risk assessment. Information from the initial assessments had been written into the plan of care. The care plans are reviewed on a monthly basis by staff. Care plans demonstrated that staff actively promoted the rights of people who use the service of access to the health services both within the home and the community. Appointments are planned or arrangements are made for professionals to visit frail people using the service. Wherever possible continuity of care for the service users’ declining state of health is assured. District nurses are called upon to assist with clinical help, equipment and advice where necessary. The Care Manager promotes the key worker system robustly so that relationships between key staff and individuals are enhanced. The Care Manager stated that the key workers have commenced compiling the “Books of Life Stories” of all people using the service. The relatives and friends of people using the service were also involved in this process. Information obtained through this process will enable care staff to increase their knowledge and understanding of the individual people who use the service and their particular needs. Visitors are able to meet people using the service in their bedrooms, in the lounges and visitors’ room on the ground floor, which offers privacy when not being used. It was observed that people using the service were being treated with respect and staff were working both professionally and sensitively in meeting individual needs. The Inspector spoke at some length with several people using the service and all of them commented positively about their care and they felt that they have everything that they need. Six people who use the service stated that “the carers are very good and kind and they look after us very well”. Three other people using the service said “the carers are always there to help”. Generally people using the service appeared to be content, comfortable and happy. They were complimentary regarding the quality of their lives and the care they were receiving at Ashley Court – care home. Discussions with the Care Manager and the staff training records showed that all senior carers and several carers have completed their training in safe handling of medication. However, it is the home’s policy that only the senior members of staff would be responsible for the safe handling and administration of medication. Medication rounds were observed during the inspection. Senior staff were seen to administer and record when medicines have been given. Records seen included medication received, administered and leaving the Ashley Court DS0000058006.V342135.R01.S.doc Version 5.2 Page 14 home. It was also seen that the mobile medication trolley was securely and safely stored after use in the medication room. The photographs of people using the service have been provided on medication sheets to avoid any risks of maladministration of medication. Ashley Court DS0000058006.V342135.R01.S.doc Version 5.2 Page 15 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. Everyone using the service are able to exercise choice with regard to social, and recreational activities at the home. Activities provided meet the needs of everyone who use the service. Relatives and friends are encouraged and assisted to maintain contacts with people using the service. The food provided at Ashley Court is of good quality and choices are always available. EVIDENCE: The home provides an activities programme in accordance with everyone using the service, their choices, preferences and capacities in relation to – social, leisure and cultural interests. People using the service, who were able to give opinion, were very complimentary about the activities provided, and particularly the external entertainers. People using the service are enabled to enjoy a full and stimulating life style with a variety of options to choose from. A record of activities participated in is kept and photographs of major events displayed in the home. People using the service were seen sitting in the lounges chatting to staff and visitors and in other communal areas within the Ashley Court DS0000058006.V342135.R01.S.doc Version 5.2 Page 16 home. Several people using the service stated that they preferred to sometimes sit quietly in their bedrooms and the staff respected this. The home now provides a hairdressing room in the new extension. Several people using the service spoken to stated that they were in regular contact with their family members and friends, and spoke about their visitors’ involvement and interest in their care matters. The visitors’ book kept in the home showed a considerable activity. The people who use the service also keep contacts with the local community – for example, church services, pubs, shops and park. A visitor from a local church regularly visited the home to give holy communion to four people using the service. The church representative told the Inspector that “the home provides a good service and the staff are very caring and they are pleasant”. The Care Manager stated that the people using the service were positively encouraged and helped to exercise their choices, and control over their lives and daily living, subject to risk assessments in terms of safety, security and capacity to make certain decisions. The Care Manager also stated that a close liaison is maintained with the relatives and representatives, where the people using the service are not able to make certain decisions. The relatives of people using the service and their representatives are informed of the availability of the Advocacy Service based at the local Age Concern. The information about the Advocacy Service is included in the home’s Statement of Purpose and Service Users’ Guide. Several people using the service told the Inspector “the home is very good and its peace and quite here”. “The food was very nice well cooked and tasty”. The consensus of people using the service was the range, quality and choice of food provided was very good and the home catered for those people using the service, who have individual preferences and medical needs. The Care Manager stated that the menu is changed on a regular basis in consultation with the people who use the service. The kitchen is well equipped and kept clean and tidy, which meets the requirements of the local Council’s Environmental Health Department. The catering staff are trained in food safety and hygiene matters. Ashley Court DS0000058006.V342135.R01.S.doc Version 5.2 Page 17 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. There is a clear Complaints Procedure in place, a copy of which is made available to people who use the service and their relatives. This should ensure that any complaint made are listened to and acted upon. The home has an Adult Protection policy and procedure to protect people who use the service from all forms of abuse. EVIDENCE: The home has a good Complaints Procedure in place, which is referred to in the home’s Service Users’ Guide and in the Statement of Purpose. There is a system of recording concerns and complaints. The Commission for Social Care Inspection (CSCI) has not received any complaints about the care home. Nor have there been any adult protection issues. The staff training records showed that ten members of staff have received training in adult protection issues. The Care Manager stated that new members of staff who as yet have not undertaken this mode of training will do so shortly. People using the service were seen to speak easily to staff and were comfortable in their company. Staff are trained in communicating with people with Dementia to ascertain their well-being. Ashley Court DS0000058006.V342135.R01.S.doc Version 5.2 Page 18 Several people who use the service stated that they were satisfied with the service provision, feel safe and well supported by staff that have their protection and safety as a priority. Ashley Court DS0000058006.V342135.R01.S.doc Version 5.2 Page 19 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. General standard of the environment is providing a homely and secure place to live in. The ongoing cleaning schedule maintains the standard of hygiene throughout the home. EVIDENCE: The home offers a comfortable and well-maintained environment to people who use the service. The home has ample communal space – three lounges, dining area and a visitors’ room. The home has a rolling programme of redecoration to maintain good standards. The garden and patio areas were well - maintained. The home has implemented all the requirements and recommendations contained in the recent inspection reports of the Fire Safety Officer and the Environmental Health Officer. Ashley Court DS0000058006.V342135.R01.S.doc Version 5.2 Page 20 The home has provided suitable aids and adaptations in the home to meet the general and specific needs of people who use the service. Bedrooms entered into were personalised according to individual wishes and tastes. Communal areas were clean and comfortable. People using the service have access to a large garden and patio areas, which have been recently improved after the completion of building works on the new extension to the premises. During the day of inspection, the home was found to be clean, tidy and free from any unpleasant odour. The home has good policies and procedures in place regarding infection control. The staff training records showed that all members of staff with the exception of two members of staff have completed their training in infection control. The two members of staff who as yet have not undertaken this mode of training will do so shortly. In addition, all members of staff have received induction training and they are made aware of the dangers of cross-infection. Ashley Court DS0000058006.V342135.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Ashley Court is adequately staffed by well – trained staff to meet the needs of people using the service. There are robust recruitment procedures in place to protect people who use the service. There is good training programme in place that ensures staff are competent to do their jobs. EVIDENCE: Information provided by the home and available staff rotas for the weeks commencing 28th May and 4th June 2007 on the day of inspection indicated that the home is adequately staffed. There is one senior carer and two carers on duty throughout the day and two carers on wakeful duty at night. There is adequate catering and domestic staff cover provided. The vacant post of a carer (40 hours per week) was being filled and the new carer to commence her duties on 11th June 2007. At least 60 of care staff group have achieved their NVQ Level 2 qualification. Those carers who as yet have not achieved this award will undergo this training shortly. The home does not employ Agency staff. The staff team is a well-balanced group in terms of age, experience and ethnicity. Ashley Court DS0000058006.V342135.R01.S.doc Version 5.2 Page 22 Six staff files were examined in detail in order to check compliance with the recruitment requirements. All six files contained copies of two written references and a full employment history. There was evidence on staff files that all six had been subject to satisfactory Criminal Records Bureau and POVA checks prior to being appointed. All staff were given copies of the General Social Care Council’s Code of Conduct and they sign to verify that they have received it. There was evidence on files that staff have received the statements of their terms and conditions of employment. There is a staff training and development programme in place. In addition to the mandatory training (see NMS OP38) staff have also taken part in Dementia Care, Adult Protection, Mental Capacity Act 2005, and Equality and Diversity. Staff confirmed that training is provided and there are many equal opportunities to improve themselves for the benefit of the care of people using the service. People who use the service commented that they feel safe with the staff caring for them and they felt that the home employs people that are capable of carrying out their care duties. Ashley Court DS0000058006.V342135.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 and 38. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The ethos of the home is based on openness and respect with effective quality assurance systems developed by a qualified and competent Manager to achieve good outcomes for people who use the service in all areas of care and maintenance of safe and secure environment. EVIDENCE: The Care Manager/Owner – Mrs Narinder Bachra has completed her required qualification to meet the standards. She has achieved her NVQ Level 4 and RMA qualifications. Ashley Court DS0000058006.V342135.R01.S.doc Version 5.2 Page 24 The Care Manager organises training events and updates staff to complement their roles within the home. Observations made and discussions with people who use the service and their relatives and staff indicated that the Care Manager is very approachable and she operates an open door policy. People using the service, who could express themselves stated that they are happy to approach the Manager and staff with any problems they might have and were confident that they would respond to them appropriately. Through discussions with the Care Manager, she demonstrated that she is confident in her ability to lead a staff team whilst being fully aware of the individual needs of people using the service. There is an emphasis on continually improving her performance through research into best practice in older people and dementia care. Equality and diversity for people using the service were seen to be promoted throughout the home within the assessments, care plans, and activities. Equality for staff is promoted through the opportunities for training at all levels. Quality Assurance takes place throughout the service in both a formal and informal manner. Meetings, surveys, internal audits, day to day contact all provide records to show that the satisfaction of people who use the service is at the heart of the service. Financial records and administrative procedures relating to the handling of monies of six people who use the service were inspected and were found to be well ordered and maintained. The Care Manager stated that the home actively encourages people using the service, where able, to manage their own money. The home keeps records to show that health and safety of people who use the service is promoted and protected. However, it was noted that the hot water supply in the bathroom on the first floor was tested to be at 48 Degrees C and the sink in the shower room on the ground floor was out of order. The staff training records showed that a majority of staff have received their mandatory training in safe working practice topics. The Care Manager stated that all those new members of staff who as yet have not received mandatory training in safe working practice topics would do so shortly. They will also receive training in Adult Protection, NVQ Level 2 and Dementia care. People using the service spoken with were very complimentary about the Care Manager and staff in the home. They knew who they were by names and looked at ease in their presence. Ashley Court DS0000058006.V342135.R01.S.doc Version 5.2 Page 25 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 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 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 3 X 3 X X 2 Ashley Court DS0000058006.V342135.R01.S.doc Version 5.2 Page 26 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 OP18 Regulation 13 (6) Requirement All staff must receive adult protection training to ensure that people who use the service are not at risk of harm or abuse. Timescale for action 31/08/07 2. OP38 23 (2)(j) Action must be taken to ensure 30/06/07 that the hot water supply in the bathroom on the first floor is assessed and appropriate controlled mechanisms are put in place in order to minimise the risks of scalding of people using the service. 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 OP7 Good Practice Recommendations It is recommended that the details and quality of daily care recording should be further improved. Ashley Court DS0000058006.V342135.R01.S.doc Version 5.2 Page 27 2. OP19 It is recommended that the system should be put in place to ensure that the essential repairs such as those identified in this report are dealt with promptly. It is recommended that all new members of staff receive training in respect of Fire Safety, Health and Safety, First– Aid, Food Hygiene, and Infection Control in order to ensure the safety of people using the service. 3. OP38 Ashley Court DS0000058006.V342135.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Ashley Court DS0000058006.V342135.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!