Inspection on 28/12/05 for Ashley House

This inspection was carried out on 28th December 2005.

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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashley House 01/11/06

Ashley House 14/06/05

Ashley House 18/10/04

Ashley House 21/06/04

Ashley House 01/07/03

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Ashley House Ashley House 33 Sunnyside Road Clevedon North Somerset BS21 7TL Lead Inspector Nicola Hill Announced Inspection 28th December 2005 09:30 Ashley House DS0000008081.V265046.R01.S.doc Version 5.1 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 DS0000008081.V265046.R01.S.doc Version 5.1 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 Adults 18-65. 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 DS0000008081.V265046.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ashley House Address Ashley House 33 Sunnyside Road Clevedon North Somerset BS21 7TL 01275 871557 01275 872528 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) Miss Anne Ball Mrs June Lloyd Mr Trevor John Gilpin Care Home 16 Category(ies) of Learning disability (16), Learning disability over registration, with number 65 years of age (16) of places Ashley House DS0000008081.V265046.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th June 2005 Brief Description of the Service: Ashley House is registered to accommodate up to 16 residents with learning difficulties. The home is a Victorian property set in large attractively maintained gardens and within easy reach of shops and other local facilities. Ashley House DS0000008081.V265046.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of Ashley House took place over the Christmas period when all the residents were expected to be home. The manager was present throughout the inspection as were several other members of staff. On arrival the inspector was introduced to the residents at the home, and initially spent time talking with them to discuss how their Christmas celebrations had been, and also how they liked living at Ashley House. The inspector also toured areas of the home with the residents, and where residents were willing, visited personal bedrooms. The inspector then reviewed care documentation held on part of residents at home with them. The documentation and records viewed at home during the inspection included care plans, the health and safety implementation, complaints and adult protection procedures, the recruitment and staff training records, and the individual staff file which hold information on staff identification and contracts. The atmosphere at Ashley House to inspection was very comfortable and informal. Later in the day relatives visited the home and spoke briefly with the inspector and reiterated their satisfaction with the standards of care at home and quality of life offered to people living at Ashley House. There has been a recent change in the ownership of the home, with Mr. and Mrs. Gilpin becoming joint owners with June Lloyd and Ann Ball. This will have no effect on the day-to-day running of Ashley House. What the service does well: From the perspective of the residents, the home provides a very supportive and homely environment. Residents are supported to make informed decisions about their day-to-day life at home, and how they like to spend their time. Some residents were very pleased to talk with the inspector and to show their personal belongings and rooms. The bedrooms were clean and tidy with personalised belongings, the residents were able to reiterate that things in the room they had chosen to be there for example pictures of family and friends were in rooms and put on walls. The residents also stated that their was plenty to do at Ashley House, and that they were taken to various activities in the community. Some of the residents also that they are able to walked to the local shops and have done since they moved to the home. Generally the residents felt Ashley House was a good place to live and that they enjoy being there. The staff at the home during the inspection were all very positive and welcoming to the inspector. There were no negatives identified about Ashley Ashley House DS0000008081.V265046.R01.S.doc Version 5.1 Page 6 House, and one member of staff stated that although the pay could be higher, the job satisfaction out weighed the low pay. One of the residents relatives also informed the inspector that they were very pleased with support given to their relative at Ashley House, especially since they were now themselves getting older. They stated that they had every confidence that should anything happen to them, then the home would be able to continue to care in an exemplary way for their relative. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ashley House DS0000008081.V265046.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashley House DS0000008081.V265046.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 The home provides information for potential residents but not in an accessible format. EVIDENCE: The manager and the inspector discussed at length the admission process, which had been followed for the newest resident to the home. From the date of referral to admission was approximately 8 weeks and during this time the manager visited the prospective resident at their original placement on four occasions, he also requested that the assistant manager visit the prospective resident on one occasion to reaffirm his impression of the care needs of the resident. The manager also held a review with social worker and family and had advice from the occupational therapist as to the specialist need of the resident, and for any specialist equipment needed for them to ensure that the presenting needs could be fully met by Ashley House. Providing understandable information to prospective residents remains a challenge especially if, as in the case of this resident, they have a visual and hearing impairment. However a relative acted on behalf of the resident and the service user guide was given to the resident’s father who also visited the home prior to the admission. The inspector and the manager discussed how to make the service user guide more easily understood to residents with learning disabilities who also may have other physical impairments. It was suggested Ashley House DS0000008081.V265046.R01.S.doc Version 5.1 Page 9 that the manager tried to prepare a short video or DVD of the home showing the main areas of the home and possibly some of the staff team so that when residents arrive for pre-admission visits they may be able to recognise some areas of the home. This of course will not be foolproof for all residents as they have differing needs, but may help inform residents who do not have the ability to read. The manager was able to verbally inform the inspector of the action here taken prior to the new person being admitted, however the pre-admission visits undertaken by the resident (3) were not recorded. In future pre-admission visit will be recorded on a daily record which will be started for the prospective resident, this will allow the event to be fully recorded and reactions of the resident to the home under the resident to be noted. Because of the nature of the resident disabilities, the usual overnight visit was omitted, and the resident stayed for daytime visits which included meeting at the resident and having meals at the home. In the resident’s care file is very detailed pre-admission assessment, which covered all aspects of care provision, and this was supported by documentation provided by care manager, and his previous home. It was noted that the pre-admission assessment made by Ashley House was not dated, and this should have provided a baseline assessment of the level of support needed by the resident, and therefore must be dated so that it had validity. The inspector was able to read that the residents have individual contracts on file and these are signed by the resident. The resident who spoke with the inspector stated that they had gone through the contract with a key worker, who had explained the contract and what it meant to them and therefore they were happy to sign the contract to ensure they could stay at Ashley House. The inspector and the manager discussed fee levels at Ashley House, and some of the resident have not had a fee increase since admission to the home several years ago. This understandably impacts on the ability of the home to redecorate and refurbish the physical environment, and to provide activities and holidays for the residents. The manager is aware that he must start negotiating these of on an individual basis and provide information to the placing authorities about the level of support provided by the home. Ashley House DS0000008081.V265046.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Resident involvement in care planning is clearly demonstrated. EVIDENCE: The inspector was able to review some of the care plans with the residents. The residents were aware that the care files were held on their behalf at the home, and that they were able to look at the plan should they wish to. One was quite happy to go through the care file and discussed with the inspector the information that was held there. The care files all follow a basic format and contain individual information about the resident, their history, and current situation. All the care plans are reviewed, and residents are involved in the review. The information contained in them is very comprehensive but is written in clear English that the residents understand, wishes and needs are reflected well. The plans are of a high quality and are a pleasure to read. The use of pictures and symbols within the file allowed to greater understanding by the resident. Some of the residents at the home are unable to comprehend the information on the care files in its present format, but the staff at the home liaise very closely with family and carers to ensure that the information Ashley House DS0000008081.V265046.R01.S.doc Version 5.1 Page 11 held is correct and that the resident lifestyle is based on their own personal choices as far as possible. The inspector was able to observe the interaction between the staff and residents. There is an informal easygoing relationship and resident have no problems approaching staff for any reason. Residents also have choices presented to them in such a way as they are empowered to make a decision. There is a regular residents meeting which is chaired by one of the support workers, and residents who wish to attend due do. The minutes of the meeting were available and the inspector was able to see that general issues were discussed, and all of the day-to-day events that happened within the home. Some of the residents are allocated tasks around the home, which they take great pride in achieving, and are paid a small amount of money for doing. The allocation of household tasks supports the independence of the resident and enabled them to maintain their skills. The personal risk assessments for the residents were discussed in depth with the manager. The risk assessments for resident should be supporting them to take that as part of an independent lifestyle. The risk assessments currently on file tend to be generic risk assessment related to aspects of care need. For example some residents have a risk assessment if they have epilepsy, despite the fact that control measures such as regular medication, monitoring of seizures are in place as part of their care plan, but there is no crossreferencing to this. The inspector and the manager also discussed the concept of risk and what was actually a hazard. For example, scalding in a bath is not a hazard if the control measures for anyone having a bath are always in place. This would be an environmental risk assessment, which involved the whole house rather than just an individual. This is an area for development for the home. Ashley House DS0000008081.V265046.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,17 The residents at Ashley House follow a chosen lifestyle supported by the staff team. EVIDENCE: The residents at Ashley House have a very active life, and attend colleges, day centres, drop in groups, and regular social groups such as the Gateway Club. Those who are able to, access the local shops independently. Several of the service users also are members of local churches and attend church services and functions. Within the home the inspector was able to see audiovisual equipment for residents to use, and several residents have their own television and stereo in their room to use when they wish to. Ashley House also has its own transport and staff take residents out on a regular basis. All the residents have any monthly activity sheet held on the care file that identified where they are all certain days of the month. This was very Ashley House DS0000008081.V265046.R01.S.doc Version 5.1 Page 13 informative for the inspector to look at, and go through with residents who were able to point out which Christmas parties and events they had attended. Visitors are welcome to Ashley House, and were observed by the inspector to be welcomed by both staff and residents, and also integrated as part of the community of Ashley House. The meals offered at home were dictated by the preferences voiced by residents, who stated there was a good variety and good quantity of food. The inspector spoke with the cook who stated that working at Ashley House was the best job she had ever had. The kitchen was extremely clean and well organised, with sufficient storage space for fresh food and vegetables. The home is able to cater for specialist diet, and can provide pack lunches for residents to take out on day care. The menu provided by Ashley House for the residents is planned on the known preferences of the residents and they are also asked as part of the residents meeting what they would like to eat. These meals are obviously variable, and therefore the menu is not planned too far in advance. Ashley House DS0000008081.V265046.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 The residents are supported to achieve optimum health and wellbeing. EVIDENCE: The residents confirmed to the inspector that they were happy with the personal support provided by the staff at my home. For example, one resident was able to tell me how she managed to bathe, and what support she had with washing her hair. The inspector was also able to observe the staff helping residents with grooming, and offering supportive advice on what should be worn appropriate to the temperature. The residents all appear very well cared for, well groomed, with coordinated clothing. The physical and health-care needs identified as part of the care planning process are in the individual care files. This includes any access to health-care providers such as opticians or dentists. The specialist services of the community learning disability team are accessed as and when necessary. One resident has support from the hospice at home team from St Peters. The medication at the home is the unit dosage system, which was checked and found to be up-to-date with no omissions on signatures for the administration of medication. The staff are working through the workbook provided by the Ashley House DS0000008081.V265046.R01.S.doc Version 5.1 Page 15 pharmacy supplying the unit dosage system. There is a picture of each resident on the medication file, and information on the medication that had been prescribed. The inspector checked the “when required” medication which had not been included in the unit dosage system. Although the stock control sheet indicated when stock had arrived from the pharmacy and when they had actually been put into the medicine cabinet for use, there was no check available on when new boxes were opened. The stock levels were not carried forward on a month-to-month base. The inspector advised the manager that they should be done so that there is an audit trail of the “when required “ medication and he understood this. The inspector was able to see from the medication should that a minimum number of drugs were prescribed to residents, and the manager confirmed that all the residents had had health checks and medication reviews in the last 12 months. Currently none of the residents at the home take medication independently, apart from the occasional inhaler. The inspector was very impressed to see that on each care file the wishes of service used to following their demise was identified. The information sheet identified what sort of service the resident would like, where they would like service to take place, and what flowers and reading they would like. For some service users these wishes were obtained from the family, but for others who spoke with the inspector they were there own wishes should and were consulted about what was written down. Because this had approach has been taking to Ashley House the inspector was able to discuss this with residents without any distress being caused. Ashley House DS0000008081.V265046.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The residents at the home know about and use the complaints procedure. EVIDENCE: The home had not received the up-to-date contact details for adult protection and was unaware of the new system, which had been put in place by North Somerset Council. The inspector advised the manager of the new contact details and this will be included in the adult protection information held at the home. The inspector was able to read the complaints file held up the home, and noted that two complaints had been made since the last inspection. Both of the complaints were made by residents and relate directly to the day-to-day running of the home, predominantly these should complaints related to the relationships between residents, and were resolved amicably. There were no other complaints listed. Ashley House DS0000008081.V265046.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 30 Ashley House provides a homely environment for its residents. EVIDENCE: The inspector did not tour the environment on the occasion however the manager informed the inspector that the carpet identified in the bedrooms on the last visit had been replaced, as has the carpet in the dining area of the home. It was acknowledged that the home is in need of general redecoration, and the inspector advised that part of the archway in the kitchen were beginning to flake paint and therefore would need repainting. The manager has plans for the redecoration of the home in order to brighten the area up, which currently is in a very dark blue, and also to replace some of the carpet in some bedrooms. This is an ongoing process as Ashley House is an old Victorian home that requires regular maintenance and updating. The inspector also raised the question of the fire escape from the top floor of the building, which appeared to be pink, with no signage, locked, and exited through a bathroom. The manager explained that he did not have the original plans for the home and therefore did not know if it was a designated fire escape or not, however, a recent visit from Avon Fire and Rescue Service had Ashley House DS0000008081.V265046.R01.S.doc Version 5.1 Page 18 not picked this issue up at problem. The inspector will follow this up with Avon Fire and Rescue Service to ensure that the fire escape is properly identified and properly signed if it exits via the doorway through the bathroom. If the Avon Fire and Rescue Service have not designated this as a fire escape, then the inspector would recommend replacement of the door and it does not provide the best facility for residents using the bathroom. Ashley House DS0000008081.V265046.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 The staff are trained to support the identified needs of the residents. EVIDENCE: The staffing at the home was discussed in depth with the manager as the residents on Wednesdays all go to different activities. It was agreed that when resident numbers fall then the staffing levels can be adjusted accordingly, for example, on Wednesdays when several of the residents are out to day centres, then the number of staff on duty could be reduced to two, not including the manager. However, it was explained that the number of staff on duty is actually dependent on the level of support needed by the residents, and that this was worked out on a formula devised by the Department of Health. The inspector will notify the manager using the identified dependency levels of the resident what level of staffing is required. The staff rota indicated that there is three staff per shift, with two staff sleeping in over night. The manager worked Monday to Friday in addition to the care staff numbers, but often transports residents to and from activities. The statutory training for staff is up-to-date, however, the learning disability award framework has yet to be implemented in the home. The staff are supported with NVQ, and the manager was advised to use his contacts with the Ashley House DS0000008081.V265046.R01.S.doc Version 5.1 Page 20 Avon Residential Care Homes Association to obtain funding for any additional training deemed to be necessary for staff. Currently there is one part-time vacancy for weekend work. The inspector reviewed the individual staff files and noted the recruitment process used for staff. The newest member of staff does not have a health declaration, although other members of staff have completed one as part of the recruitment process. The manager was advised to get the number of staff to complete the health declaration to that they are fit physically and mentally to carry on working at the home. The staff are supervised by the manager predominantly, although this has not always been on a formal basis. There is no appraisal system, but most staff have had a formal supervision session at least three times in the last year. The manager is planning for the future that some supervision is delegated to the assistant manager. The home also has a deputy assistant manager and more senior home support workers than basic support workers. The manager is aware that he must streamline the management structure so that they are clear lines of accountability and he can delegate some of the managerial work. Ashley House DS0000008081.V265046.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41, 42, 43 The home is run for the benefit of its residents. EVIDENCE: Currently the manager is working towards achieving the registered manager award. The manager and his wife have recently bought into the partnership for the home and now have 25 of the business. Trevor Gilpin remains as the registered manager for the home and has the day-to-day responsibility of the running of the home including staff recruitment and provision of correct staffing levels. Rachel Gilpin (his wife) deals with all the financial side of the home that relate to be invoicing, wages, and paying bills. However the responsibility for major decisions still lies with the other owners of the home, and this occasionally causes you difficulty and both of these partners spend majority of their time in Spain. It is noted that although Ann Ball (majority partner) visits the home occasionally, no regulation 26 reports have been Ashley House DS0000008081.V265046.R01.S.doc Version 5.1 Page 22 recorded. Ann Ball as the majority partner for the home must complete regulation 26 visit reports and these must be forwarded to the commission. The service users at home were spontaneous in their comments of appreciation about the staff team and about the way in which they live. Several of the resident had lived in institutions for the majority of their lives and appreciate the easy-going and informal atmosphere at Ashley House. They are also very aware of the necessity to respect each other’s privacy. The staff at the home all have some area of responsibility allocated to them, one of the staff has care plans another has health and safety etc. The resident meetings are recorded, and the management of the home has daily contact with the residents so that the residents are able to raise any issues of concern. The evidence of this is recorded in the complaints folder, and also the inspector of confirmed with residents that have they were able to raised areas of concern to them. The residents stated that they would do this with the staff team or the manager, and were adamant that any problem should be raised and not allowed to carry on, as this would cause them to be unhappy. The policies and procedures at the home had not been reviewed since the manager was appointed. It will be a long process and should be undertaken over a period of time. The health and safety of the residents is promoted by the implementation of policies within the home, which protect them and support their welfare. There was evidence that the water system had been tested for Legionella, Fire Safety precautions were in place and had been checked on a regular basis, there is the health and safety monthly audit of the home taken place and any issues of concern identified by the sordid were action. The risk assessment in place at home for fire safety is an example of how it should be completed, rather than an actual risk assessment. This has bought the attention of the manager who will ensure that the risk assessment is completed appropriately. There were a number of minor accidents recorded, none of which required admission to hospital or any prolonged treatment. The manager was advised to record any monies, cheques and bank books/cards held on behalf of residents in such a way that it is clearly auditable and therefore easily monitored. Evidence of the financial viability of the home was requested from the manager, who will contact the accountant for the home and the bank and ensure that a statement is sent to the Commission. Ashley House DS0000008081.V265046.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 2 3 3 3 3 3 3 Ashley House DS0000008081.V265046.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA43 Regulation 26 Requirement Ann Ball as the majority partner for the home must complete regulation 26 visit reports and these must be forwarded to the commission. Timescale for action 28/12/05 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 3 4 5 Refer to Standard YA20 YA9 YA1 YA41 YA42 Good Practice Recommendations The stock level of the when required medication must be carried forward on a monthly basis. Risk assessments must be linked to care plans. Information for potential residents should be presented in a more accessible format e.g. a video/DVD. The manager is advised to keep clear records for any financial transactions completed on behalf of residents. Following confirmation from Avon Fire and Rescue Service, the manager should renew the exit door from the upstairs bathroom. Ashley House DS0000008081.V265046.R01.S.doc Version 5.1 Page 25 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. Extracts may not be used or reproduced without the express permission of CSCI Ashley House DS0000008081.V265046.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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