Inspection on 23/01/07 for Ashley House

This inspection was carried out on 23rd January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 House 15/01/09

Ashley House 13/03/06

Ashley House 14/07/05

Ashley House 31/01/05

Ashley House 24/08/04

Ashley House 19/02/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Ashley House The Avenue Langport Somerset TA10 9SA Lead Inspector Kathy McCluskey Unannounced Inspection 09:45 23 January 2007 rd 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 DS0000016071.V305655.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 DS0000016071.V305655.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashley House Address The Avenue Langport Somerset TA10 9SA 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) 01458 250386 01458 250386 South West Care Homes Ltd Susan Frances Timbrell Care Home 25 Category(ies) of Dementia - over 65 years of age (0), Old age, registration, with number not falling within any other category (0) of places Ashley House DS0000016071.V305655.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. REGISTERED FOR 25 OLDER PERSONS IN CATEGORIES OP AND DE (E) WITH A MAXIMUM OF 6 DE(E) Date of last inspection Brief Description of the Service: Ashley House is situated in a residential area close to the centre of Langport. Service user accommodation is provided over two floors. There is a stair lift, assisted bathrooms and call system available at the home. Most rooms have en suite toilet facilities. Communal areas comprise of a lounge, dining room and large conservatory. The home has pleasant gardens that are accessible via ramps and wide steps. The home’s current fees are between £382 and £412 per week. Additional charges are met by service users for hairdressing, toiletries, chiropody, newspapers/magazines. Ashley House is registered with the Commission for Social Care Inspection to provide care for up to 25 people over the age of 65 years who require assistance with personal care. Within the maximum number of 25, the home may accommodate up to 6 older people with dementia. The home is not registered to provide nursing care. The Registered Manager is Mrs Susan Timbrell. The Registered Provider is South West Care Homes Ltd. The home has a social services quality rating. Social services currently have a contract for 9 of the home’s beds. The home determines who is suitable to be admitted. Ashley House DS0000016071.V305655.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of this inspection visit was to inspect relevant key standards under the Commission’s ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are; - excellent, good, adequate and poor. This unannounced Key inspection was conducted over one day (7hrs) by CSCI regulation inspector Kathy McCluskey. At the time of this 23 service users were living at the home and the inspector was able to meet with the majority of them. Two staff were spoken with in depth. The registered manager was available throughout the inspection and the inspector was given unrestricted access to all areas of the home. As part of this key inspection, the commission sent comment cards to service users, relatives and GP’s. Responses were poor. Only one comment card was received from a service user and one from a relative. The registered manager informed the inspector that service users had also completed questionnaires from social services and were reluctant to complete any more. A tour of the premises was carried out and records were examined relating to service users, staff and health & safety. The inspector would like to thank service users, staff and the manager for their time and cooperation with the inspection process. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. What the service does well: Ashley House provides a comfortable and homely environment for service users. The home ensures that prospective service users are fully assessed prior to a placement being offered. Admission will only take place once the home are sure that they can fully meet the assessed needs of individuals. Ashley House DS0000016071.V305655.R01.S.doc Version 5.2 Page 6 The inspector met with the majority of service users and all confirmed that they were very satisfied with the care they received. All stated that the staff were kind and that they were treated with respect. The inspector observed staff interactions with service users to be warm, kind and respectful. The home is managed by an experienced registered manager who promotes an open and inclusive style of management. The manager is very much ‘hands-on’ and has a good awareness of the needs and preferences of service users. Staff and service users informed the inspector that the manager was very approachable and was ‘always willing to listen’. A quality assurance programme is in place which regularly seeks the views of service users. The home ensures that appropriate staffing levels are maintained and increased where necessary. Staff have been appropriately trained. Correct procedures are followed for the management and administration of service users medication. A range of activities is available to service users. The home has robust systems in place which reduce the risk of harm or abuse to service users. The home takes appropriate steps to ensure the health and safety of service users and staff. What has improved since the last inspection? What they could do better: It has been required that the registered person ensures that staff receive formal supervision at least six times a year. It has also been required that bath hot water outlets are checked monthly to ensure temperatures do not exceed 44c. Please contact the provider for advice of actions taken in response to this Ashley House DS0000016071.V305655.R01.S.doc Version 5.2 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ashley House DS0000016071.V305655.R01.S.doc Version 5.2 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 House DS0000016071.V305655.R01.S.doc Version 5.2 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): 3, 4 and 5. Standard 6 is not applicable as the home is not registered to provide intermediate care Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Prospective service users are fully assessed by the home to ensure that assessed needs can be met. Service users are encouraged to visit the home and are offered a trial period. EVIDENCE: The registered manager ensures that prospective service users are fully assessed prior to a placement being offered. Pre-admission assessments were seen in the care plans examined and copies of assessments from healthcare professionals were also in place. Social Services currently have a contract with the home for 9 of the 25 beds. The home’s assessments procedures are followed and the registered manager Ashley House DS0000016071.V305655.R01.S.doc Version 5.2 Page 10 determines whether the home can meet individual’s assessed needs and whether admission will be offered. Emergency admissions are avoided and only considered if appropriate assessments are available. Service users spoken with during the inspection informed the inspector that they had been given the opportunity to visit the home prior to making a decision to live there. Two service users informed the inspector that they had decided to move to the home following a period of respite. The registered manager informed the inspector that she would not offer admission to a service user unless the home were sure that their assessed needs could be met. The manager was able to provide examples of this. Ashley House DS0000016071.V305655.R01.S.doc Version 5.2 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 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The home has an effective care planning system in place. The home’s procedures for the management and administration of service users medication are good. Service users are treated with respect. EVIDENCE: Two service user care plans were examined at this inspection and both contained sufficient information pertaining to the individual’s assessed needs and preferences. Care plans had been reviewed at least monthly and the inspector was able to see evidence that the service user had been involved in agreeing their plan of care. Ashley House DS0000016071.V305655.R01.S.doc Version 5.2 Page 12 The home takes appropriate steps to ensure that service users healthcare needs are met. The manager stated that the home had excellent links and support from healthcare professionals. Service users weights are monitored monthly. The inspector examined the home’s procedures for the management and administration of service users medication. The home uses the monitored dosage system (MDS) with pre-printed medication administration records (MAR). All available MAR charts were examined and were found to be well maintained. Photos of service users were attached to their MAR chart to aid identification. All medicines were found to be appropriately stored. Medication is only administered by senior staff who had received appropriate training. The home’s last pharmacy community advice visit was conducted on 19/09/06 and no issues were raised. Approximately 20 service users were spoke with at this inspection. All confirmed that they were treated with respect and that their privacy was respected. Interventions between staff and service users were noted to be very kind and respectful. Ashley House DS0000016071.V305655.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 and 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users have the opportunity to participate in a range of activities. Service users exercise choice over their lives. Service users benefit from a wholesome and varied menu. EVIDENCE: Service users were keen to tell the inspector that they choose how and where to spend their day. Service users confirmed that they could enjoy the privacy of their own bedrooms if they wished and that they chose what time to get up or go to bed. Service users are encouraged to personalise their bedrooms. Service users confirmed that the home had a programme of activities which they could join in with if they wished. A particular favourite appeared to be the ‘sing-a-longs’ with an outside entertainer. Ashley House DS0000016071.V305655.R01.S.doc Version 5.2 Page 14 The home encourages suggestions from service users though some activities which have recently taken place include; crosswords, scrabble, light exercises, Sunday hymns, discussions and stories. No relatives/visitors were seen during this inspection though service users informed the inspector that their visitors were made welcome at any time and they could choose where to see their visitor. All visitors are required to sign in the visitors book. The registered manager confirmed that there were no service users currently using an advocate but that age concern would be contacted as required/requested. Contact details are available at the home for service users. All meals at the home are freshly prepared by the cook. The home makes good use of fresh produce and service users spoken with were positive about the meals available. Some comments received were; ‘there’s always plenty to eat’, ‘you can have what you want when you want it’, the meals are very good’. During the inspection the inspector was able to see lunch being served. The dining room was comfortable and homely. Tables were attractively laid. Cloth napkins, condiments and a selection of drinks were available. Service users appeared relaxed and enjoyed the lunch time experience. Ashley House DS0000016071.V305655.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 and 18 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure in place. The home takes appropriate steps to reduce the risk of harm or abuse to service users. EVIDENCE: The home has a satisfactory complaints procedure which, as recommended at the last inspection, is displayed in the reception area of the home. Service users spoke with informed the inspector that they would not hesitate in raising concerns if they had any. The registered manager stated that the home had not received any complaints since the last inspection. No concerns have been raised directly with the commission. The home takes appropriate steps to reduce the risk of harm or abuse to service users. Staff recruitment procedures are robust and staff have received training on abuse. Ashley House DS0000016071.V305655.R01.S.doc Version 5.2 Page 16 The inspector spoke with two staff during the inspection and both demonstrated a good knowledge of the ‘whistle-blowing’ policy and how to raise concerns with external agencies. Ashley House DS0000016071.V305655.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, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Ashley House provides a comfortable and homely environment for service users. The home provides appropriate aids and adaptations for service users though one bathroom would benefit from assisted bathing facilities. Service users are encouraged to personalise their private space. EVIDENCE: Ashley House is situated in a quiet residential area in Langport. It is a large detached property which has been adapted and extended to provide accommodation to 25 older people. Ashley House DS0000016071.V305655.R01.S.doc Version 5.2 Page 18 The home has been fitted with a number of aids and adaptations to assist service users. A stair lift provides access to the first floor, grab rails are appropriately sited throughout the home and call bells are fitted throughout. The home has one mobile hoist, which the manager and staff confirmed was adequate to meet the needs of the current service user group. Two of the home’s three bathrooms provides assisted bathing facilities. The registered manager informed the inspector that there are plans to provide this provision in the upstairs bathroom also. Given that many of the service users would benefit from assisted bathing, it has again been recommended that this work is carried out. Bedrooms are located on the ground and first floor of the home. The home has 21 single bedrooms and 2 shared bedrooms. Nineteen single bedrooms have en-suite toilet facilities and two of this are also fitted with a bath. The two double bedrooms are both fitted with en-suite toilets. Communal areas are all located on the ground floor and consist of a lounge, dining room and very large conservatory. All communal areas and a selection of bedrooms were seen. Communal areas appeared very comfortable and well utilised. Bedrooms were comfortably furnished and it was apparent that service users were encouraged to personalise their private space. The home appeared clean though the upstairs bathroom had a very offensive malodour. The registered manager advised that they were in the process of addressing this problem. This will be followed up at the next inspection. To ensure the privacy of service users, it has been required that the missing lock on the upstairs bathroom is replaced. It should be of a type which can be over-ridden by staff in the case of emergencies. All service users spoke with informed the inspector that they were ‘very comfortable’ at the home and that they liked their bedrooms. Not all bedrooms have lockable space though the commission was previously informed that this was in the process of being addressed. Progress will be monitored at the next inspection. The home was found to be comfortably warm at the time of the inspection. Radiators are guarded to reduce the risk of injury to service users. Radiators in corridors which are narrow cannot be guarded but these have been disabled and do not have an impact on the temperature of the home. The laundry area was not seen at this inspection. Ashley House DS0000016071.V305655.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensures the needs of service users are met by adequate numbers of staff who have been appropriately trained. The home’s staff recruitment procedures are robust and reduce the risk of harm or abuse to service users. Photographs are required for staff. EVIDENCE: Staff duty rotas were made available to the inspector. The registered manager advised that, for the current service user numbers of 23, the home is staffed as follows; Mornings (0700-1400) 3 care staff Afternoon/eve (1400-2100) 2 care staff An additional carer is on duty between 1630 and 2030hrs. Nights are covered by one waking and one sleep-in care staff. Care staff spoken with did not express any concerns about staffing levels and confirmed that they were able to meet the needs of service users. No concerns were raised by service users spoken with. Ashley House DS0000016071.V305655.R01.S.doc Version 5.2 Page 20 The registered manager and staff spoken with, confirmed that staffing levels would always be increased to meet assessed needs of service users where required. The registered manager also advised that where the numbers of service users exceeded 23, staffing levels would be increased by one care support in the afternoon/evening. In addition to care staff, the home employs a cook and domestic staff. The registered manager is generally in addition to care hours though occasionally provides ‘hands on’ care. The registered manager provided the inspector with pre-inspection information which indicated that 10 of the 13 care staff employed have achieved a minimum NVQ level 2 in care. This equates to 77 which exceeds the national minimum standards recommendation of 50 . The home operates robust staff recruitment procedures. Two staff recruitment files were examined at this inspection and both contained all information required. The inspector was also able to see evidence that staff had not commenced employment before a Criminal records check (CRB) and Protection of Vulnerable Adults check (POVA) had been received. The home does need to ensure that an up to date photograph of the employee is maintained in their file. Staff spoke with confirmed that they were satisfied that they had received the training needed to perform their duties. Staff also confirmed that they had received a satisfactory period of induction. The inspector was unable to view staff induction programmes at this inspection so this will be followed up at the next inspection. The registered manager confirmed that all staff had received up to date mandatory training which included moving and handling, fire, health and safety and first aid. A selection of certificates were made available to the inspector and the registered manager advised that a training matrix was in the process of being created on the computer. This will be examined at the next inspection. Additional training that has taken place includes, understanding dementia and abuse. Staff spoken with were positive about the training they received. Ashley House DS0000016071.V305655.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, 32, 33, 34, 35, 36, 37 and 38 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The home is managed by an experienced manager who promotes an open and inclusive style of management. The home has a quality assurance programme which seeks the views of service users. The home takes appropriate steps to ensure the health and safety of service users, staff and visitors. EVIDENCE: The registered manager is Susan Timbrell. She has managed the home since 2002. Ashley House DS0000016071.V305655.R01.S.doc Version 5.2 Page 22 Susan has 13 years experience in caring for older people and has achieved an NVQ level 4 in management. The registered manager promotes an open and inclusive style of management and is very much ‘hands on’. Service users and staff were very positive about the manager and stated that she was very approachable and ‘always willing to listen’. The inspector noted that service users were very relaxed in the presence of the manager and that she was very aware of individual’s needs and preferences. Regular meetings are held for staff and service users. Minutes of the most recent meetings were made available to the inspector. Meetings were well attended and appropriate topics were discussed. The registered manager informed the inspector that, as part of the home’s quality assurance programme, questionnaires are sent to service users and other stakeholders on an annual basis. The manager was unable to locate the results of the most recent survey but informed the inspector that they were due again this year. The company’s responsible individual completes monthly reports/visits where the views of service users and staff are sought. Reports are made available to the commission. The home displays an appropriate employers liability insurance certificate which expires 23/11/07. The home manages small amounts of money on behalf of service users as requested. A sample of records and balances were checked. The home maintains appropriate records and obtains two signatures for transactions. Receipts are also available. Regular audits are carried out. The home has systems in place to ensure that staff are appropriately supervised. Records made available to the inspector did not indicate that staff were receiving formal supervision at least six times a year. Detailed records were seen for 2003 and 2004. Only one supervision record was available for 2005 and 2006. A requirement has been raised that this is addressed. All records seen were found to be appropriately maintained and stored in accordance with the Data Protection Act 1998. The home takes appropriate steps to ensure the health and safety of service users, staff and visitors. This was ascertained by a tour of the premises and on examination of the following records: FIRE SAFETY – The home conducts weekly checks on the home’s fire alarm systems and carries out weekly visual checks on fire fighting equipment. Records indicated that this was last carried out on 18/01/07. Ashley House DS0000016071.V305655.R01.S.doc Version 5.2 Page 23 Monthly checks are maintained on emergency lighting. This was last completed on 20/12/06. Regular fire drills take place. Records indicate that this last took place on 17/10/06. ELECTRICAL SAFETY – The home has a current electrical hardwiring certificate dated 04/02/03, valid for 5 years. The inspector was able to see evidence that work required, had been completed. Annually testing on portable appliances took place on 15/01/07. Nurse call systems were also checked by an external contractor on 15/01/07 and the home maintains weekly checks. GAS SAFETY – The home has an up to date annual Landlords gas safety certificate dated 06/03/06. EQUIPMENT SERVICING – Six monthly servicing, in accordance with LOLER regulations, were found to be up to date. The home’s mobile hoist was serviced on 30/11/06, stair-lift on 30/11/06 and two bath hoists on 30/11/06. ACCIDENTS – the home maintains appropriate records relating to accidents. Accident records viewed were unremarkable. Accidents are analysed by the manager on a monthly basis. The home uses an accident book which conforms with the Data Protection Act 1998. As staff accidents would be recorded in the same book at service users, the registered manager was advised that pages should be removed when completed. HOT WATER OUTLETS/SURFACES - Hot water outlets have been fitted with thermostatic valves to ensure that temperatures can be set at a safe level. It was noted that although weekly checks are made on the temperatures of outlets in wash hand basins in communal areas, no checks were being carried out for communal and en-suite baths. It has been required that monthly checks are carried out in accordance with guidance from the Health & Safety Executive (HSE), to ensure that bath hot water outlets do not exceed the recommended upper limit of 44c. To ensure the safety of service users, radiators in use are guarded, free standing wardrobes are secured to the wall and upstairs windows are restricted. The registered manager confirmed that immediate action would be taken to restrict the upstairs window identified at the inspection. The home’s kitchen was inspected by an environmental health officer on 09/01/07. No issues were raised and it was stated that ‘the premises were clean and tidy’. Ashley House DS0000016071.V305655.R01.S.doc Version 5.2 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 x 3 3 3 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 3 3 3 3 2 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 2 3 2 Ashley House DS0000016071.V305655.R01.S.doc Version 5.2 Page 25 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 OP29 Regulation 19(4)(b) & Schedule 2 18(2) Requirement The registered person must ensure that a recent photograph is obtained for staff employed. The registered person must ensure that staff are appropriately supervised. Formal supervision should take place at least six times a year. To ensure the health & safety of service users, the registered person must ensure that monthly checks are maintained on all bath hot water outlets to ensure that temperatures do not exceed 44c Timescale for action 30/03/07 2. OP36 30/07/07 3. OP38 13(4) 15/02/07 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 OP22 Good Practice Recommendations The bathroom on the first floor should be suitably adapted to provide assisted bathing facilities for service users. DS0000016071.V305655.R01.S.doc Version 5.2 Page 26 Ashley House 2. OP24 It is recommended that the plan to provide furniture with lockable space in all bedrooms is carried out. Ashley House DS0000016071.V305655.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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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