Inspection on 21/11/06 for Ashley House

This inspection was carried out on 21st November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ashley House 09/05/08

Ashley House 24/05/07

Ashley House 09/11/05

Ashley House 11/05/05

Ashley House 09/11/04

Ashley House 02/06/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Ashley House Moulsham Street Chelmsford Essex CM2 9AQ Lead Inspector Mrs Nikki Gibson Key Unannounced Inspection 09:30 21st November 2006 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 House DS0000017753.V314598.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 House DS0000017753.V314598.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashley House Address Moulsham Street Chelmsford Essex CM2 9AQ 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) 01245 494674 01245 493254 Dr Kuldip Singh Dr Amrit Kaur Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Ashley House DS0000017753.V314598.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, only falling within the category of Old Age (not to exceed 22 persons) 16th May 2006 Date of last inspection Brief Description of the Service: Ashley House is a large detached house, located in a residential area close to a park and a supermarket, and only a short distance from the centre of Chelmsford. The home has parking to the front, and a garden area to the rear. Accommodation is over two floors, with access via a through floor lift. There are ten single bedrooms (two with en-suite toilets) and six double bedrooms (one with en-suite toilet). The home has three bathrooms, several toilets, and two communal lounge areas (one with an integrated dining area). The home is registered to provide care and accommodation to 22 older people; it does not provide nursing care, and is not registered to admit residents with a diagnosis of dementia. The home is currently being run by one of the owners, Mrs Singh and the registered manager’s post remains vacant. The most recent inspection report was displayed by the entrance door. In November 2006 all fees were £426.08p for both single and shared rooms. Residents paid additionally for hairdressing, chiropody, newspapers and personal toiletries. Ashley House DS0000017753.V314598.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which covered all the key National Minimum Standards. The site visit took place over 11 hours by one regulation inspector. During the visit there was a tour of the premises and a selection of records and documents were studied. Time was spent in the lounge and dining room observing practice, and with residents in their own rooms. Seven residents were spoken to about life at Ashley House. The inspection process also included discussions with the proprietor, some staff on duty, and relatives. Once contact details have been provided by the proprietors surveys will be sent to the District Nursing team, the GP Practice and social work teams who are involved in the home. A pre-inspection questionnaire was sent to the home but not returned within the requested time scale despite numerous reminders. This was considered as an indication of poor management in the home. The proprietor, staff, and residents were most helpful throughout the inspection and this was greatly appreciated. Discussion of the inspection findings took place with one of the proprietors throughout and at the end the inspection and guidance was given. What the service does well: What has improved since the last inspection? While not all shortfalls from the last inspection have been addressed there was evidence that some progress had been made particularly with the care plans and staff training files. Care plans were being reviewed and developed. There are plans to incorporate continence assessment, Medication profile and risk assessments, but it was disappointing that these were not yet on care files. The home has filled the post of manager and the new person should start in the new year when all her checks and references have been taken up. Ashley House DS0000017753.V314598.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ashley House DS0000017753.V314598.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 Ashley House DS0000017753.V314598.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 346 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home gathers information about each resident prior to offering a place. Residents and families are generally happy with the level of care provided. EVIDENCE: The proprietor stated that unless it was an emergency or they lived a great distance she would always visit a potential resident before offering them a place. In addition to the information (comp 5) provided by their social worker she would complete her own pre-admission assessment. Many comments from residents and relatives about the home were positive and they said that staff treated them well. From observation staff were seen in most parts to have the skills to meet residents needs. However, one frail resident who was unable to weight bear was seen being moved using a manual lift which put her at risk of injury. A few of the more able residents said they felt that standards had dropped particularly in relation to having to wait for Ashley House DS0000017753.V314598.R01.S.doc Version 5.2 Page 9 assistance from staff. One relative said that she felt that staff knew her mother and met her needs in a caring manner. Ashley House does not provide Intermediate care. Ashley House DS0000017753.V314598.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care plans continue to improve although some gaps still remain. Some shortfalls in the administration of medication were noted which could have put the residents at risk. Some routines in the home do not allow for individual needs and are institutional. Resident’s health care needs were being met. EVIDENCE: Several care plans were studied. Some were of the old format and others were a new format which the home is gradually introducing. Both provided clear instructions for staff on the care needs identified. However, some important information about residents, for example previous health concerns, was not in the care plan. The proprietor said this information was probably stored separately. It was advised that all relevant medical histories are available in the care plan as a central resource for all care staff. Not all relatives/residents spoken to were aware of their care plans. The proprietor was keen to ask advice about the standard of the homes moving and handling risk assessments. She was advised that the format was appropriate, however greater detail in the content would be an improvement. The home is introducing a medical profile and a continence assessment in each care plan Ashley House DS0000017753.V314598.R01.S.doc Version 5.2 Page 11 which was viewed positively. It is expected that these will be completed on each file by the next inspection. The home may like to try the Malnutrition Universal Screening Tool (MUST) when undertaking nutritional screening. Details of this and other helpful information around meals and nutrition can be found on the CSCI bulletin ‘Highlight of the Day?’ on the CSCI web site www.csci.org.uk The home has introduced a separate page in the care plan for recording visits or contact with the medical profession. This provides a quick reference and more detailed information was in the care plans and daily notes. There was documented evidence that the home was working closely with the Parkinson’s Disease Nurse Specialist to the benefit of one of the residents. It was pleasing to note that daily notes were written by the member of staff who provided the care. It was noted that a number of residents remained in their chairs throughout the whole day. Each resident had a cantilever table over their legs which may have discouraged them from getting up and moving about. Breakfast and tea was eaten by all residents in their armchairs. At lunchtime a number of residents again remained in their chairs. Staying in one position all day has many disadvantages and while residents should have a choice it is important to consider why residents do not move and what can be done to encourage movement and exercise. This should be recorded in their care plans. The systems for the administration of medication were inspected. Storage and administration of medication were not safe for both general and controlled drugs. Keys to the medicine trolley were left in the office and should have been carried by the person in charge, in line with the guidance of the Royal Pharmaceutical Society of Great Britain. The wall cupboard containing a stock of medication was not locked. The controlled drugs cupboard should be used for controlled drugs only. An appropriate Controlled drugs book is required, that is a register that is bound and with numbered pages. The Medication Administration Records (MAR) sheets are all hand written and the home is advised to ensure each entry is signed and dated. They are also advised that it is good practice to get it checked by a second person. The recording on the MAR sheet should include all the supplementary instructions on the label as they are there to ensure the optimum effect of the medication, e.g. ‘take before meals’ or ‘take with water’ etc. Although the number of pills received is recorded in the receipt book it is good practice to record it on the MAR sheet as this will make the homes auditing easier. The home is advised against using codes such as ‘ii tds’ as this can easily lead to medication errors. One resident was asking staff for a paracetamol. As there were no homely remedies a staff member said she was planning to give paracetamol prescribed Ashley House DS0000017753.V314598.R01.S.doc Version 5.2 Page 12 for another resident. This was discussed and explained that this practice was unacceptable. The home now plans to review its Homely Remedy policy. On the day of inspection it was noted that one medication had been decanted and was left in the kitchen. It was acknowledged that this was to assist staff to give the medication at the correct time, however it is not acceptable practice as it is open to a number of risks. As an alternative the person responsible for administering the medication could use a timer. The home was advised that Temazepam is a Schedule 3 drug and must be kept in the Controlled drugs cupboard. If the blister pack does not fit in the CD cupboard they must ask the pharmacist to dispense it in a different container. Patient information leaflets must be available in the home for all the drugs being administered including those in the bubble packs. In general residents described the staff as caring and staff were heard speaking to residents with respect. Incidents relating to a lack of residents’ choice which also compromises their dignity is detailed in the next section of the report. Some screening was present in shared rooms between the beds which gave limited privacy. Residents said that they wear their own clothes. Residents preferred names are recorded on their care plans. Ashley House DS0000017753.V314598.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is a narrow range of activities and limited contact with the local community. Visitors are made welcome. Residents’ choices are limited and there is a tendency for the routine to be institutional. EVIDENCE: On the day of the inspection activity both mental and physical was very limited for most residents. A number of residents and a couple of visitors said they would like more to do and that they were frequently bored. One resident said that there were games and puzzles in the home but they are not often used. A lack of activities was also raised in resident and relative surveys. Two staff have done some training in providing activities for older people but this could not be seen being put into practice. This is an aspect of care that needs to be developed. Interaction between residents and staff was jovial and volunteers in the home did spend time sitting with residents. One resident said she missed the regular church service which used to take place and the proprietor was informed, she said she would contact the local church and try to rekindle the link. Visitors are welcome at anytime and arrangements can be made for visitors to eat a meal with their relatives. Drinks are offered to visitors who visit at a ‘drink round’ time. Ashley House DS0000017753.V314598.R01.S.doc Version 5.2 Page 14 A number of residents and visitors to the home spoke of residents being told to wait when they asked to be assisted to the toilet. One visitor said she had been present when her relative had been made to wait over an hour to be taken to the toilet. This was a recurring complaint and similar incidents were confirmed by both relatives and residents. One resident asked the inspector if it was ‘toilet time’ yet. When asked if she would like a carer to be called she said it had been ‘drummed’ into her to only go at toileting time. A relative said in a survey that ,’Toilet trips are at specified times which causes great distress and bladder problems as peoples bodies are all different.’ The home has a toileting programme which needs to be more flexible and adapted to each residents needs. Staff said that residents start getting up at 5.00 am and some request to go to bed straight after tea. Evidence that this is the real choice of residents should be recorded in the care plans. One resident said that they went to bed at 6.00 pm and did not watch television in their room because staff liked them to settle down to sleep. Dinner is served at 12.30 pm, however cutlery was being placed on residents over lap tables at 10.50 am. This could be very confusing for some residents and also would indicate that residents would not be expected to move or undertake any other activity prior to lunch. The above examples of practices in the home would indicate that routines and tasks are the focus of the home rather than the individual choice of the residents. Changes in practice must be made to make the residents’ wishes the focus of the home. Residents said that they enjoyed the food served. On the day of the inspection the meal looked and smelt appetising and residents said that the meat was tender. There is no true choice but residents are informed of the meal and alternatives can be provided for example corned beef. One resident with cultural food requirements obtains meals from the local Indian Take Away and this is supplemented by meals made by the proprietor. One resident who liked vegetarian meals had cheese plus the vegetables other residents had on the day of inspection. A member of staff said she had the same meal the previous day. The home is required to review its menu and consider providing a true choice and greater variety. Ashley House DS0000017753.V314598.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has appropriate Abuse and Complaint policies, however not all staff had received adequate training and all complains are not recorded and investigated. EVIDENCE: Some residents spoken to made reference to not wanting to be seen as complaining while clearly dissatisfied with some aspects of care. This lack of confidence to express their views is a delicate issue, which will need to be treated with great sensitivity. Relatives told the inspector of concerns with regard to the toileting regime which they said they had raised with the proprietor, however they had not been logged in the complaints book and had not been resolved. The concern that complains are made but not recorded or resolved was also raised in a survey. During the inspection concern was raised by a resident about the care provided by one member of staff. The proprietor was prompt to discuss the views with a number of residents, her approach was open and sensitive to all concerned. The manager plans to follow up her enquiries to ensure that residents feel safe and respected in the home and staff receive guidance and training. A similar incident arose at the last inspection and may relate to the same member of staff. A copy of the investigation should be included in the home ‘Improvement plan’. Ashley House DS0000017753.V314598.R01.S.doc Version 5.2 Page 16 Not all staff have received Protection of Vulnerable Adults training. The home has a video and work book but as yet not all staff have received this training. To protect residents this should be undertaken by all staff as a matter of urgency. Ashley House DS0000017753.V314598.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 20 24 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Ashley House provides a warm and comfortable environment which is homely yet rather run down. The kitchen requires refurbishment so that hygiene standards can be met EVIDENCE: At Ashley House there is a main lounge area and connected dining area. There is a small quiet lounge for residents which is also used by the district nurses, chiropodist, hairdresser and visitors. It was poorly decorated and uninviting. One chair in the room was broken and there was cabling on the floor, it lacked comfortable chairs and the lighting was poor. Concerns that this room does not offer appropriate facilities for the residents has been raised at previous inspections. The proprietor said that she plans to order ten new comfortable chairs. The dining area had an area where tiles had fallen from the wall which detracted from the homely feel of the room. Ashley House DS0000017753.V314598.R01.S.doc Version 5.2 Page 18 The home has a high proportion of shared rooms and these are proving not to be so popular. Rooms had been personalised and residents had been able to bring in personal items and small pieces of furniture. None of the rooms had lockable facilities or door locks and this was said to be the choice of the residents. Carpets in many rooms were in need of vacuuming. Toilet rolls and continence aids were on display in many rooms. The proprietor was advised that tidier and more discreet storage would help maintain the dignity of residents. The kitchen was organised and tidy, however the worktops, cupboards and floor are very worn with broken surfaces which would seriously hamper adequate cleaning. Doors were broken off some cupboards and there was serious burn damage to one worktop. The cupboards under the sinks contained cleaning materials and food substances. There was a leak under one sink and dirty water was collected in a bowl and next to it was stored bottles of fruit squash. The home has been saying for some time that they intend to refurbish the kitchen and it now needs to addressed as a matter of importance. The laundry was inspected. There was no separate hand washing facilities and staff wash their hands in the butler sink where soiled clothes are soaked. The laundry also lacked any liquid soap. Cleaning materials which are hazardous to health such as Bleach and toilet cleaner were see in various places in the home with easy access to the residents. This is a potential risk and these items must be kept locked away. The toilet frame in one bathroom was very badly worn and it would not be possible to adequately clean it. Staff were observed toileting residents, serving food and assisting residents to eat without a change of apron. It was considered that the standard of infection control in the home was poor and the home is advised to seek the guidance of the Essex Health Protection Unit which is based at 8 Collingwood Road, Witham, Essex CM8 2TT. 01376 302282 Ashley House DS0000017753.V314598.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staffing levels are not being maintained at a level that satisfactorily meets the residents’ needs. Staff recruitment needs to be more robust to protect the residents and staff induction should meet recognised standards. EVIDENCE: Three residents and a visitor said at the inspection that they felt the standard of care had dropped particularly with regard to how long they have to wait for assistance and they put it down to the home not having sufficient staff to meet all the residents needs. In a survey a relative said more night staff were required and there was not sufficient domestic staff. A resident said in a survey that a lack of staff at night led to unacceptable waits at night. The proprietor must make a review of the required staffing levels. This should include sufficient catering and domestic staff. Staff should not be expected to undertake catering or domestic duties which takes them away from the care of the residents. It was pleasing to note that following the last inspection staff training and development records have been introduced. The proprietor is further advised to draw up a matrix of all staff and courses. This will enable her to see what training is required to ensure that staff on duty have the appropriate skills and knowledge. Ashley House DS0000017753.V314598.R01.S.doc Version 5.2 Page 20 A random selection of staff files were requested. A file for one new member of staff was not available for inspection. On a second file an application form was not included. One application seen did not include a photograph, only had one reference and did not include a full employment history. The recruitment practice in the home must be more robust so that it protects residents. A new member of staff said that she had received three days of induction training so far, however she was not aware of anything being recorded. Care must be taken to ensure that the Induction programme meets the Care for Skills standard. Ashley House DS0000017753.V314598.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 36 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has been without a manager for years and this is reflected in standard of care and record keeping. EVIDENCE: Ashley House has been without a manager for several years. The proprietor was keen to provide a good standard of care and staff were hard working and committed. However, the proprietor was clearly struggling and documentation and information required by the CSCI in the form of a Pre-inspection questionnaire was not provided at the time of the inspection. A member of staff said that once a manager was in place she felt the home would be better organised and would run smoother. A visitor said the home was not as well organised as it used to be. The proprietor stated that a new manager was being recruited after Christmas and references and checks would be in place Ashley House DS0000017753.V314598.R01.S.doc Version 5.2 Page 22 before she worked in the home. An application to register the new manager is expected by the CSCI in the New Year. The new manager will need supernumerary time to undertake her management duties. The proprietor gave a commitment to support and help the new manager and staff settle into the new management structure. The proprietor said that the home has a Quality Assurance system in place which includes questionnaires for residents and relatives and that an annual report is sent to the CSCI each year. The home holds money in safe custody for residents. One set of records was selected at random and the figures and cash balanced. The home was advised to ensure that there is a receipt for each transaction. Staff are receiving regular supervision and a new format for the recording of these sessions is being tried out. Aspects of health and safety in the home were inspected. As stated earlier concern was raised regarding the standard of infection control in the home and the working condition of the kitchen. Fire prevention equipment is checked regularly and records kept. The fire alarms are tested monthly, when the expectation of the CSCI is that it is done weekly. The proprietor said that this was with the agreement of the Fire officer. She is advised to confirm with a senior Fire Officer that this is correct. Ashley House DS0000017753.V314598.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 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 1 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 2 X X X 2 X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 1 3 X 2 3 X 2 Ashley House DS0000017753.V314598.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement The Registered Person must prepare a written plan with consultation with the resident as to how their needs will be met Timescale for action 15/01/07 2 OP9 13 3 OP12 16(2) This refers to continuing the improvements started and ensuring all residents have the opportunity to be involved in their care plan and that they are regularly reviewed. 15/01/07 The Registered Person must make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the home. This refers to safe storage, accurate records, safe administration and medication must not be decanted. Greater detail is provided in the body of the report. (Previous timescale of 30.11.05 not met) 15/01/07 The Registered Person must consult with residents about their interests and provide a programme of activities and Ashley House DS0000017753.V314598.R01.S.doc Version 5.2 Page 25 provide facilities for recreation. 4 OP14 12(4) The Registered Person must ensure that the home is conducted in a manner that respects the privacy and dignity of residents. This refers specifically to staff attending to residents request to go to the toilet promptly. The Registered Person must maintain a record of all complaints about the operation of the Home and the action taken. The Registered Person must make arrangements to prevent residents from being abused. This refers to policies being known to staff and training being provided. The Registered Person must ensure that the premises are kept clean and reasonably decorated. This refers to the need for improved cleaning, the decor and missing wall tiles. The Registered Person must ensure that the communal space is suitable. This refers to the small lounge which needs to be refurbished. The Registered Person must make suitable arrangements to prevent infection, toxic conditions and the spread of infection in the home. This refers to the kitchen, laundry and poor infection control practices. The Registered Person must ensure that adequate staffing levels are maintained. This refers to reviewing the staffing level required and adjusting the staffing level accordingly. The Registered Person must ensure that robust recruitment DS0000017753.V314598.R01.S.doc 15/01/07 5 OP16 17(2) 15/01/07 6 OP18 13(6) 15/01/07 7 OP19 23(2)(d) 15/01/07 8 OP20 23(2)(h) 15/01/07 9 OP26 13(3) 15/01/07 10 OP27 18 15/01/07 11 OP29 Schedule 2 15/01/07 Ashley House Version 5.2 Page 26 12 OP31 8(1)(b)(i) procedures are in place, and applied consistently. Records required by regulation in respect of staff recruitment must be obtained prior to a staff starting work. The Registered Person must take 15/01/07 action to register a manager with the CSCI as soon as possible. (Previous timescale of 30.11.05 not met) 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 2 Refer to Standard OP7 OP8 Good Practice Recommendations The registered person should, where possible, involve residents or their supporters in the development of their care plans and that this should be evidenced. Opportunities should be given for residents to undertake in more exercise and movement. Residents should be encouraged to eat at a dining table to improve posture, and improve social interaction It is recommended that the home purchase a pre-printed, formal controlled drugs record book. It is recommended that links with the local community are fostered. It is recommended that a greater choice of meals are made available with consultation with the residents. It is recommended that continence pads are stored in a manner which maintains the dignity and privacy of the resident. It is recommended that the registered person establish a planned programme for replacing furniture that is becoming worn. This should include the provision of lockable storage facilities for service users. The registered person should keep domestic staffing levels under review, to ensure that cleaning and hygiene needs are being maintained in the home. 3 4 5 6 7 OP9 OP13 OP15 OP24 OP19 8 OP27 Ashley House DS0000017753.V314598.R01.S.doc Version 5.2 Page 27 9 10 OP35 OP38 It is recommended that all financial transactions with resident’s money are accompanied by a receipt. It is recommended that further advice is obtained in writing regarding the frequency of testing of the fire alarm. Ashley House DS0000017753.V314598.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ashley House DS0000017753.V314598.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. 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