Inspection on 09/11/05 for Ashley House

This inspection was carried out on 9th November 2005.

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

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

Other inspections for this house

Ashley House 09/05/08

Ashley House 24/05/07

Ashley House 21/11/06

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 Kathryn Moss Unannounced Inspection 9th November 2005 09:30 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.V263989.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ashley House DS0000017753.V263989.R01.S.doc Version 5.0 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.V263989.R01.S.doc Version 5.0 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) 11/05/05 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 ensuite toilets) and six double bedrooms (one with ensuite 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 service users with dementia. The previous assistant manager, Denise Starkfield, is now the manager of the home, assisted by one of the owners, Dr Kaur. The manager has yet to submit her application for registration with the CSCI. Ashley House DS0000017753.V263989.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on the 9th November 2005, lasting nine hours. With the permission of the owner of the home, the inspector was accompanied by the Community Liaison Nurse for care homes in mid Essex, who was primarily present to observe the CSCI inspection process, but also spoke to several residents and provided advice on care related issues. This report represents evidence and information gathered as part of the inspection. The inspection process included: discussions with the owner and acting manager; discussions with nine residents and two visitors; inspection of the premises; and inspection of a sample of staff and service user records. The focus of this inspection was on core standards that had not been inspected at the last inspection, and on standards where there had been previous requirements or recommendations (not all previous recommendations were reviewed on this occasion). 22 standards were covered, although not all elements of each standard were fully inspected; 8 requirements (including 3 repeat requirements) and 13 recommendations have been made. On the day of the inspection, the home had a comfortable and friendly atmosphere, and service users spoken to appeared content and made positive comments about living at Ashley House. What the service does well: What has improved since the last inspection? Ashley House DS0000017753.V263989.R01.S.doc Version 5.0 Page 6 The proprietor and manager had taken action to address several previous requirements since the last inspection. Radiator covers had now been fitted to all radiators, and individual staff files had been implemented to enable better organisation and storage of staff records. There was also evidence of a good care plan for pressure area care for one resident, containing clear information on the support required of staff to meet this person’s specific needs, and showing a good response to meeting this previous requirement. Another improvement since the last inspection was that more staff were now doing NVQ level 2 in care, and that the manager was in the process of doing the Registered Manager’s Award (NVQ 4 in Management). Additionally, the proprietor had attended a manual handling trainer’s course, the cook had completed food hygiene training, and a number of staff had attended some training on relevant care issues. 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.V263989.R01.S.doc Version 5.0 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.V263989.R01.S.doc Version 5.0 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): 3 and 4 The needs of new residents are assessed prior to moving into the home, and the home has the facilities and staff skills to meet the stated aims of the home. EVIDENCE: The files of two new residents were inspected, and contained evidence of initial assessments carried out prior to admission. The home’s assessment form covered an appropriate range of issues, covering health, personal care, and social/cultural needs, and had space at the end for the assessor to sign and date the form; completed assessments contained brief details of the person’s main abilities and needs. One file also contained a care management assessment. The manager was encouraged to actively assess people’s needs prior to admission wherever possible, following an incident when information provided by hospital staff had not accurately reflected a person’s level of need. Residents and visitors spoken to during the inspection all felt that staff had the skills to carry out the care required, and residents were satisfied that staff met their needs. The home had appropriate facilities to meet the needs of the people it aimed to accommodate (e.g. through floor lift, assisted baths, mobile hoist, etc.). Staff training is referred to in the section on Staffing. Ashley House DS0000017753.V263989.R01.S.doc Version 5.0 Page 9 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 and 9 Health care needs were being appropriately met. Care plans described the action needed to meet the health and personal care needs identified; however, they did not always identify and address all of a person’s needs, and the home lacked systems for carrying out full assessments and risk assessments on specific needs. The home’s medication practices were generally satisfactory, but there was no written policy/procedure to reflect the practices expected. EVIDENCE: The files of two new residents were viewed for evidence that their personal and healthcare needs were being met, and to see if care plans set out their personal, healthcare and social needs. Residents observed and spoken to appeared well cared for, and were happy with the care and support that staff gave them with their personal care. Their clothes looked clean, and they reported that they were happy with the way their clothes were laundered; a visitor commented that the person they visited always looked clean and tidy. Staff were observed to interact with residents in a caring and respectful manner, and to be attentive to their needs. Ashley House DS0000017753.V263989.R01.S.doc Version 5.0 Page 10 Initial assessments carried out prior to admission provided a general overview of the person’s main abilities and needs. However, it appeared that the information provided prior to admission for one person had not been accurate, and the home’s assessment had not been revised after admission to reflect their actual needs. There were no additional comprehensive assessments/risk assessments covering issues such as moving and handling, risk of pressure areas or continence, as discussed at previous inspections. A general hazard risk assessment form had been used to identify risk of pressure areas and moving and handling risks, but this format was not sufficient for fully assessing each issue. The purpose of assessments and specific detailed assessments, and their relationship to care plans, was discussed; the manager and proprietor were advised that appropriate assessments must be implemented. Care plans inspected covered an appropriate range of needs: whilst the ‘action’ required by staff to meet the person’s need would benefit from more detail in some cases, there was some good information recorded, care plans were clearly written, and there was a good pressure area care plan present on one file. One file lacked a care plan to address personal care needs, and in the other file cultural needs relating to food and personal hygiene were not specifically noted; the manager was advised that these should be addressed. On one care plan there were clear records of the care plans being reviewed monthly. Care plans had not been signed by service users (where the service user was able) to show their involvement in developing their care plan. Daily notes were viewed for one resident who was bed bound and had a pressure sore: these provided good details of the care being given, particularly reflecting frequent checks during the night, turning, offering fluids, etc. Their care plans reflected the support they needed with pressure area care. The home maintained records of food eaten by residents each day, as evidence of their nutrition. It was good to see drinks available in the lounge throughout the day, with glasses of squash beside each person. One resident was pleased that they had been able to keep their own GP when they moved into the home, and residents reported that the home called the GP promptly if they were unwell. The home did not record all contact with healthcare professionals for each resident, although visits by the district nurse were recorded in one person’s daily notes. The manager was advised to ensure that contact with healthcare professionals be recorded. Several rooms inspected had pressure relief mattresses on the beds, where required by the resident’s needs. The home did not have a written policy and procedure relating to administering medicines in the home, and the proprietor was advised that this must be developed. Medication was stored securely in a locked medication trolley, and the home also had a controlled drugs cabinet. There were clear records of all medication received by the home and returned to the pharmacist. The Medication Administration Record (MAR) was handwritten by staff at the home, showing the medication, the dose, and when given. Theses details were signed by the person entering the information, as were subsequent changes to Ashley House DS0000017753.V263989.R01.S.doc Version 5.0 Page 11 instructions (e.g. if medication was discontinued). It was recommended that all medication details be recorded in upper case for clarity. A few gaps in the administration records were seen, and the manager was advised to audit these regularly, and also to ensure that staff used consistent codes to indicate reasons for any medicine not being taken. In the case of one medication, a difference between the dosage on the MAR and the hospital discharge information was noted, and the manager was asked to clarify this with the GP: it is important that the home has clear procedures for ensuring that they have correct medication administration instructions for residents. The home used a hardback notebook for recording controlled drugs: appropriate drugs were being recorded in this, but the layout of information was sometimes unclear. The manager was advised to obtain a pre-printed Controlled Drugs record book to enable consistent recording. The owner stated that all staff currently administering medication had received training from the pharmacist, and that the manager observes staff doing a medication round before they do this task on their own (although this is not recorded at present). The pharmacist carries out routine visits to the home each year to check on medication practices. Ashley House DS0000017753.V263989.R01.S.doc Version 5.0 Page 12 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, 14 and 15 Residents were satisfied with the lifestyle in the home, and were able to pursue recreational and cultural needs and interests. Where able, residents appeared to be able to exercise choice and control over their lives. Residents received a balanced and appealing diet. EVIDENCE: Residents spoken to during the inspection were positive about their lives at Ashley House, and did not express any concerns about daily routines. Although activities were not specifically inspected on this occasion, it was noted that the home had developed a suggested activities programme, with ideas for morning and afternoon activities each day. On the afternoon of the inspection, two residents were sitting at a table doing some drawing, and although no other specific activities were taking place, there was a lively, chatty atmosphere in the lounge: music was playing, most residents were awake and alert, some were reading and others had visitors, and staff were present in the lounge and were interacting well with residents. It was noted that each resident had a table by their chair, and many had a range of personal items present with them (sweets, tissues, magazines, etc.). Residents were seen to have choice and control over where and how they spent their day. The proprietor reported that residents and relatives meetings Ashley House DS0000017753.V263989.R01.S.doc Version 5.0 Page 13 were periodically held, and that suggestions made about changes in the home had been acted on. Rooms viewed were personalised, and there was evidence that people could bring their own possessions into the home with them. One person was still continuing to pursue their own interests, and were supported in this. It was noted on previous inspections that information on advocacy services was displayed in the hallway (this was not checked on this occasion). Access to records was not discussed on this inspection. Lunch observed on the day of the inspection looked and smelt appealing, and residents reported that they had enjoyed it and that the meat was tender. The home had a four-week rotating menu, which contained an appropriate range of balanced meals. There was one choice of main meal served at lunchtimes, but the proprietor stated that a range of alternatives were available, and that the cook went round each morning to tell people what was for lunch and to see if they wanted anything different. At most teatimes there was a cooked option available as well as sandwiches. The owner stated that they intend to carry out a survey of residents’ likes and wishes regarding meals, to help them to review the menu. The home had two vegetarians, both of whose needs were being met: one had cultural needs regarding food preferences, and this person’s needs were being well met; the owner was encouraged to explore a wider range of meal options for the other vegetarian. Residents could chose where they had their meals, and staff were observed providing assistance where required. Ashley House DS0000017753.V263989.R01.S.doc Version 5.0 Page 14 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 The home responds appropriately to complaints and concerns, and residents were confident that complaints would be listened to and acted on. EVIDENCE: The home’s complaint procedure was included in their statement of purpose/ service user guide, and had been previously noted to cover the issues required by Regulation 22 and this Standard. Service users spoken to said that they felt able to tell the manager if they had a concern or complaint about anything. The home maintained a complaints record: it was noted that no new complaints had been recorded for this year, although the inspector was aware of one complaint that the proprietor had received and investigated. The proprietor was advised that this should have been recorded. Since the last inspection, two concerns had been notified to the CSCI in relation to Ashley House. The first was found to be unsubstantiated, and the second was still being investigated at the time of this report. In both cases the proprietor and manager demonstrated a positive approach to exploring the issues raised, and worked openly and co-operatively with social services and the CSCI in investigating these. Ashley House DS0000017753.V263989.R01.S.doc Version 5.0 Page 15 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, 23, 24 and 25 On the day of the inspection the home appeared clean, and provided a safe environment; however, a few rooms required repair or renovation. The home provided service users with sufficient personal and communal space, which was homely and suitably furnished, with appropriate heating and lighting. The home had sufficient toilet and assisted bathing facilities. EVIDENCE: On the day of the inspection the home was warm, clean and safe for residents. Records of maintenance and refurbishment were not viewed on this occasion. Some bedrooms were noted to be in need of decoration: the proprietor stated that decoration of bedrooms was planned to take place over the winter. As noted at the previous inspection, some furniture was becoming worn: there were no immediate plans for this to be replaced, but the proprietor stated that this would be included in ongoing plans for improving the home. The kitchen was still in need of refurbishment, and the inspector was advised that plans for this were ongoing. The environmental health officer had recently inspected food hygiene practices. Grounds were not viewed on this visit. Ashley House DS0000017753.V263989.R01.S.doc Version 5.0 Page 16 The main lounge was open plan and was warm and homely, with different seating areas available and with a dining area off the lounge. The space was used flexibly, with most residents spending time in the lounge during the day, many of them choosing to eat lunch sitting in their chairs, and with two residents sitting at a dining room table doing some drawing in the afternoon. The home also had a second smaller lounge, which, as noted on previous inspections, was still very cluttered due to being used as a storage area, and was therefore not a safe or homely room for service users to use. The manager was encouraged to clear this room and make it available as an alternative space for residents who may want a quieter environment, a room to meet with visitors in private, or somewhere to watch TV (although the main lounge has a TV, due to its layout this area is not conducive to TV viewing). The home has ten single bedrooms and six double bedrooms: none of these were measured on this occasion, but according to previous infromation, all meet the national minimum standard for room sizes. A sample of bedrooms were viewed during the inspection: these contained appropriate furnishings and furniture to meet people’s needs, although, as noted above, some furniture was becoming worn. Double rooms viewed contained a privacy curtain, and rooms contained commodes where required. Rooms had sufficient electric sockets and overhead lighting, and all beds had a call alarm system and wall lighting close to the bed. Several rooms seen were well personalised, with evidence that the person had brought their own possessions in with them and were able to pursue their own interests. Rooms do not currently contain lockable storage facilities or locks on doors: the owner confirmed that these had been offered to all residents and would be provided if requested. She was reminded to offer this to all new residents. It was good to see that the owner had progressed work to prevent risk to residents from hot radiator surfaces, with all radiators now fitted with protective covers. Rooms were naturally lit and ventilated, the home had appropriate heating and lighting, and there was emergency lighting throughout the home. Restricted opening of upstairs windows was not inspected on this occasion. Following the fitting of temperature control valves earlier in the year, it was also noted that hot tap water temperatures were now being regularly monitored, and that hot water storage temperatures were being monitored to ensure they remained high enough to prevent risk of Legionella. There were ensuite toilets in two single bedrooms and one double bedroom; other toilets are available throughout the home (including in some bathrooms). Toilets were not inspected on this occasion. The home had three bathrooms, all of which were assisted: the manager advised that one of these has restricted space, making it less easy to use, and therefore the other two are used more. These both contained baths with integral electric bath seats: one of these seats was observed to be cracked, and the owner was advised to get this repaired as it presented a potential hazard to residents. Ashley House DS0000017753.V263989.R01.S.doc Version 5.0 Page 17 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 and 30 Staffing levels were not always being maintained at a level that satisfactorily met residents’ needs. An appropriate number of staff were undergoing training to demonstrate that they have the required level of competence (i.e. NVQ in care). The home provides training relevant to the aims and objectives of the home, but evidence of training completed was not yet satisfactory. EVIDENCE: Rotas were viewed for the week of the inspection and a previous week: both weeks showed several shifts that were one staff member short, resulting in there only being two carers on duty for part of the day. The owner explained that she was currently recruiting staff and hoped this would resolve current staffing problems. She stated that she hoped to arrange cover for shifts that were short during the reminder of that week, and subsequently confirmed to the inspector that these were covered. The owner was advised that two staff on duty was an unsafe daytime staffing level for the home, and that she must make contingency arrangements (e.g. use agency staff) for times when the home expects to be short staffed for a period of time. Rotas showed domestic cover on three days a week: the manager stated that communal areas and bathrooms were cleaned each night by the night staff, and that she hoped that care staff would do some additional domestic hours once the home was fully staffed. She was advised to ensure that there is sufficient regular domestic cover to maintain hygiene in the home. Ashley House DS0000017753.V263989.R01.S.doc Version 5.0 Page 18 The home had made progress with NVQ training since the last inspection. There were fifteen care staff employed at the home at the time of this inspection, and although only one carer had evidence of completing NVQ level 2, the manager stated that another carer had previously done this (but not yet provided evidence) and seven care staff were now in the process of doing NVQ level 2. This should ensure that over 50 of carers are trained to NVQ level 2. Staff training was not specifically inspected on this occasion. However, at the last inspection there had been a requirement that the proprietor implement individual staff training records, and this was reviewed. It was noted that this had still not been actioned: although there was evidence of a range of training certificates for staff, not all of these had been filed on individual staff files, and there was still no individual record of training attended by each person in order to be able to easily ascertain the training each person had completed or required. From certificates it was noted that several staff had attended workshops in relevant care topics since the last inspection. Ashley House DS0000017753.V263989.R01.S.doc Version 5.0 Page 19 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, 35 and 37 and 38 The manager and proprietor have relevant experience to run a care home; however, the manager is not yet registered with the CSCI. Residents’ financial interests are safeguarded through the practices and procedures in the home. The home operates appropriate practices to promote the health and safety of staff and service users. Record keeping practices and policies do not satisfactorily safeguard the health and welfare of service users. EVIDENCE: The home’s manager has now been in post as acting manager/manager for about eighteen months, supported by the proprietor to gain experience in this role. The manager had not yet submitted an application for registration with the CSCI and the proprietor was advised that this application must now be submitted as soon as possible. The manager had started her Registered Manager’s Award (NVQ level 4 in management), and had attended a variety of training to develop her knowledge and skills. Ashley House DS0000017753.V263989.R01.S.doc Version 5.0 Page 20 The home does not manage any resident’s benefits, but does look after small sums of money on their behalf. There were safe storage arrangements for this, with each person’s money kept in individual bags, and clear records for each person. Some records and monies were checked, and in one case the money and records balanced, and in the other the money was a few pence out. The manager suspected that some change had fallen out of the bag and this was rectified immediately. The owner was encouraged to implement a system for regularly auditing financial records, and to ensure that all receipts are kept and are archived with each record sheet. The manager said that valuables are rarely looked after for residents, but would be clearly recorded if required. Staff health and safety training records were not inspected on this occasion; it was noted that the cook had completed food hygiene training this year, and the proprietor had trained as a manual handling trainer. Health and safety issues inspected primarily focused on whether the home maintained appropriate checks on the facilities and equipment in the home. Records showed regular servicing of fire alarms and equipment, and emergency lighting; the home also carried out monthly checks on these, but records showed a gap between May and October this year; the proprietor was advised that these checks must be regularly maintained. There was evidence of several fire drills carried out in the home this year. The home had a current electrical installation certificate, and evidence of the testing of portable electrical appliances and the servicing of the lift and hoists. The proprietor could not provide evidence of gas safety inspection and servicing at the time of the inspection, although stated that this had been carried out. Hot tap water temperatures were being tested and recorded every other month, as were central hot water storage temperatures. These showed that hot water was maintained at temperatures that minimised a risk of scalding and of Legionella. The home’s health and safety information and procedures were not inspected on this occasion, but the home was seen to have a clear health and safety policy statement: as this was not dated, it was recommended that this be reviewed and dated. The home had an appropriate range of risk assessments carried out on safe working practice topics; it was noted that these were due for review. These included a risk assessment on chemicals used in the home. Records inspected on this occasion indicated that further improvement was still required. This particularly related to maintaining orderly systems for filing records (e.g. staff training records, health and safety records), the need for care records to cover all issues (e.g. re assessments and care plans), reviewing risk assessments and policies (e.g. health and safety), and the need to develop a medication policy. Issues relating to a recent complaint were discussed in relation to the need to keep clear records of health related issues (e.g. records of contact with healthcare professionals, changes to residents’ health when they have been away from the home, etc.). Supervision was not specifically inspected on this occasion, but a sample supervision record seen for one carer was well recorded. Ashley House DS0000017753.V263989.R01.S.doc Version 5.0 Page 21 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 X 3 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 3 3 X 3 3 3 X STAFFING Standard No Score 27 2 28 3 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X 3 X 2 2 Ashley House DS0000017753.V263989.R01.S.doc Version 5.0 Page 22 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 Care plans must address all needs, including health and personal care needs, and social and cultural needs. This is a repeat requirement (previous timescale 30/6/05) Timescale for action 30/11/05 2 OP7OP8 12, 13 and 14 3 OP9 13 4 OP9 13 5 OP27 18 It is required that the registered person implement appropriate systems for assessing specific needs (e.g. risk of pressure areas, moving and handling, continence, etc.). This is a repeat requirement for the third time (last timescale 30/6/05). It is required that the registered person implements a clear written medication policy and procedure for the home. The registered person must ensure that there are systems in place to ensure that medication administration details are checked and correctly recorded. The registered person must ensure that minimum care staffing levels are always maintained in the home, and make provision for covering expected staff shortages. DS0000017753.V263989.R01.S.doc 31/12/05 31/12/05 30/11/05 30/11/05 Ashley House Version 5.0 Page 23 6 OP30 18 7 8 OP31 OP38 8(1)(b)(i) 13 It is required that the registered 31/12/05 person implement individual training and development profiles for all staff, as evidence of training completed and to identify training needed. This is a repeat requirement for the third time (last timescale 30/6/05). The registered person must take 23/12/05 action to register a manager with the CSCI as soon as possible. The Registered Person must 30/11/05 ensure that routine health and safety checks are regularly carried out. This particularly relates to the internal testing of fire alarms and emergency lighting, checks on fire equipment, and ensuring risk assessments are regularly reviewed and updated. 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 OP3OP8 OP7 Good Practice Recommendations The registered person should ensure that pre-admission assessments are reviewed on admission, and updated to reflect any new assessment of the person’s needs. The registered person should, where possible, involve residents in the development of their care plans, and that care plans are agreed and signed by the service user (where capable). It is strongly recommended that staff record on individual residents’ records any contact with medical professionals. The registered person should ensure that medication administration records are accurately maintained. This is particularly with regard to there not being unexplained gaps in the records, and to staff using consistent codes to show reasons for any non-administration. DS0000017753.V263989.R01.S.doc Version 5.0 Page 24 3 4 OP8 OP9 Ashley House 5 6 7 8 9 10 OP9 OP9 OP19 OP19OP20 OP19OP21 OP19OP24 11 12 13 OP19OP24 OP27OP26 OP37 It is recommended that the manager clearly record any assessment of staff competence to administer medication within the home. It is recommended that the home purchase a pre-printed, formal controlled drugs record book. It is strongly recommended that the registered person progress plans to refurbish the kitchen. It is recommended that the small lounge be made into a safe and homely space for use by residents and staff. The registered person should ensure that the cracked bath seat is replaced as soon as possible. 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. It is recommended that the registered person ensure that action is taken to decorate bedrooms, where required. The registered person should keep domestic staffing levels under review, to ensure that cleaning and hygiene needs are being maintained in the home. The registered person should ensure that issues relating to record keeping practices are addressed within the home. This particularly relates to: 1. Records being fully recorded, accurate and up-to-date (e.g. assessments, care plans, risk assessments, contact with medical professional, medication, etc.); 2. Records being stored in an orderly manner, with records being available on inspections (e.g. training records, health and safety records); 3. There should be policies available to cover all core practices within the home, which are regularly reviewed and updated, and signed by the registered person. Ashley House DS0000017753.V263989.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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.V263989.R01.S.doc Version 5.0 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. 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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