Inspection on 06/11/07 for Ashley House Care Home

This inspection was carried out on 6th November 2007.

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 Care Home 03/04/08

Ashley House Care Home 21/12/06

Ashley House Care Home 03/10/05

Ashley House Care Home 19/10/04

Ashley House Care Home 20/04/04

Similar services:

Trevayler Residential Care Home

Thornham Grove

Thistle Hill Hall

Conifer Lodge

Westwood Lodge

Egerton Lodge Care Home

Alfred Minto House Care Home

St Matthews Unit

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

CARE HOMES FOR OLDER PEOPLE Ashley House Care Home Sunnyside Worksop Nottinghamshire S81 7LN Lead Inspector Stephen Benson Unannounced Inspection 6th November 2007 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 Care Home DS0000024625.V354025.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 Care Home DS0000024625.V354025.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashley House Care Home Address Sunnyside Worksop Nottinghamshire S81 7LN 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) 01909 500541 01909 500542 Ashfieldcare@aol.com Mr L M Patil Vacant Care Home 40 Category(ies) of Dementia - over 65 years of age (40), Mental registration, with number disorder, excluding learning disability or of places dementia (10), Mental Disorder, excluding learning disability or dementia - over 65 years of age (40) Ashley House Care Home DS0000024625.V354025.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The 10 Places in category MD are available for people of 50 years of age and above 21st December 2006 Date of last inspection Brief Description of the Service: Ashley House is located on the outskirts of Worksop. A car park is available at the side of the home and it is on the bus route into the town. The home provides nursing and personal care for 40 residents, including older people with special mental health needs. Within this number the registration allows admission for up to 10 service users over 50 years of age. The home is privately owed by Mr Patil and was opened in 1988. It consists of a large converted old house, with a purpose built lounge and bedroom extension on the ground floor. Plans have recently been passed by the local council to allow the owner to upgrade the home and build a 32 bed extension. There are 17 single and 9 double bedrooms, 12 rooms having ensuite facilities. The first floor is accessible by a lift. The homes grounds are well laid out and provide a secure environment for residents. At the time of the inspection the owner confirmed that the weekly fees ranged from £340 - £370 depending on the residents assessed needs. Additional charges are made for services such as chiropody, toiletries and hairdressing. Information about these costs as well as the day-to-day operation of the home are included in the Statement of Purpose and Service User Guide and a copy of the last inspection report is available in the office. Further information about the home is available on their website at www.ashfieldcare.co.uk Ashley House Care Home DS0000024625.V354025.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first visit to the home since 1st April 2007 by The Commission for Social Care Inspection. Prior to the visit an analysis of the home was undertaken from information gathered over the last year. The visit centred on looking at the key National Minimum Standards for older people. The site visit lasted for 5 ½ hours and the main method of inspection used was called case tracking which involved selecting 3 residents and tracking the care they receive through the checking of their records and discussing this with them. Other residents were spoken with and additional records were seen. A discussion was had with the provider, the acting manager, the clinical manager, staff on duty and care practices were observed. Two visitors were also spoken with during the visit. The premises were not inspected in detail but various areas of the home were visited as part of the inspection. The registration certificate was checked and found to be incorrect, as it did not show the correct provider or provider’s address. A replacement one has been requested. What the service does well: Prospective new residents are assessed before coming to the home to make sure that the home is able to meet their needs. The home will contact healthcare professionals to see to the healthcare needs of residents and their health is monitored through observation and regular health checks. Visitors are welcome to come to the home at anytime so residents can keep in contact with family and friends. Residents are able to choose how they spend their time within certain agreed limitations, and are supported by staff to make choices where they are able so that residents remain in control of their lives as much as they are able. There is a 3 week menu and there is a choice of alternatives if something different is wanted. Residents can request a particular meal if they wish to. This ensures that residents enjoy a varied and wholesome diet. The home has a complaints procedure, which is available for residents to use and there are policies and procedures for staff to follow if they suspect anyone is not being properly treated. Ashley House Care Home DS0000024625.V354025.R01.S.doc Version 5.2 Page 6 The home is spacious and suitable for people using a wheelchair. Everywhere is kept clean and tidy, suitably decorated, appropriately furnished and kept in a good state of repair, as a result residents live in a safe and well maintained environment. The home provides 5 care staff and a nurse on duty during the day and two care staff and a nurse at night. There are staff who work in the kitchen and keep the home clean. This ensures that staff are available to see to residents needs. What has improved since the last inspection? What they could do better: The Statement of Purpose and Service User Guide must be kept up to date and accurately reflect the services provided in the home so current and future residents know what they can expect. Assessment documentation should be amended to allow for information concerning residents’ ethnic origin and any significant relationship to be obtained. A record must be kept of all activities provided to show that residents are able to participate in frequent and varied activities, which are appropriate to their needs. Meals must be served in a manner that is appropriate and allows for residents’ choices and preferences. The correct recruitment process must be followed at all times, including obtaining a Criminal Records Bureau check. This will ensure that residents are protected by the home’s recruitment process. Staff must be provided with the training they need to be able to do their work. This will ensure that residents are cared for by suitably trained staff. The home must be managed by someone who has been through the registration process to be come a registered manager. Residents must have opportunities to express their views on how the home is run. This will ensure that residents can have a say in how the home is run. Ashley House Care Home DS0000024625.V354025.R01.S.doc Version 5.2 Page 7 A record must be made of every financial transaction, which is then signed and witnessed and a correct record held of the total amount of money held for each resident. A risk assessment should be in place regarding the care of the animals living in the home. A record must be made of all fire safety tests and checks that take place. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ashley House Care Home DS0000024625.V354025.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 Care Home DS0000024625.V354025.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. New residents are fully assessed prior to moving into the home to ensure that their needs can be met. The home does not offer an intermediate care service EVIDENCE: The Statement of Purpose and Service User Guide were seen and these were not up to date. Then provider said that there have been a number of changes within the home that have not been included into these documents. The care file of the most recently admitted resident was seen and this contained assessment information dated prior to the date the resident moved to the home. The assessment information did not include obtaining details regarding residents’ ethnic origin and only asked whether the person was Ashley House Care Home DS0000024625.V354025.R01.S.doc Version 5.2 Page 10 married or single and did not allow for anyone to refer to any significant relationship they have or had. The acting manager said that anyone is welcome to apply for a place providing they fall within the registration category for the home and he will amend the assessment paperwork. The acting manger said that the clinical manager or one of the nurses will go to assess any prospective new resident and he will sometimes accompany them. The acting manager said any information available from Social Services is also obtained prior to admission and there was a Social Services Assessment seen on the care file. Staff said that the nurses will tell them about any new resident in advance so they can get the room prepared for them and they are able to go to read the assessments. The most recently admitted resident was not well and was in her room. The clinical manager advised it was best not to visit her. Another resident said he had been bought to visit the home and had stayed for a two-week trial period. A visitor said that staff visited her relative in hospital to see if he was able to move to the home. There is no arrangement made for the home to provide an intermediate care service. Ashley House Care Home DS0000024625.V354025.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents’ health, personal and social needs are set out in an individual plan of care and these are met by care practices in the home. EVIDENCE: A sample of three care files were seen and these included needs identified through the assessment process. Care plans were seen for activities such as personal hygiene, aggressive behaviour, confusion and work and play. Care plans provided clear detail as to how staff should meet the needs of residents, for example one plan stated “discourage from drinking alcohol by discussing with him what happened previously…….” Another said “staff to be aware of aggressive behaviour approach in a calm smiling manner…….” Where some risk assessments identified risks to individual residents or others, these were incorporated into care plans, although one care plan was seen Ashley House Care Home DS0000024625.V354025.R01.S.doc Version 5.2 Page 12 regarding aggression that did not have a risk assessment and the clinical manager said she would attend to this. There were risk assessments seen for such activities as going missing, careless smoking and violent behaviour. There were monthly reviews recorded of care plans and risk assessments. The acting manager said that the clinical manager and nurses are responsible for keeping care plans up to date. The acting manager said he thinks care plans have improved and are now clearer and kept up to date. The acting manager said a Social Worker is coming to review one care plan later in the week and this was seen written in the diary. Staff said that they can refer to care plans at any time and that they find them useful. Staff said that if they were unsure or worried about something they go to the care plan to check what they should be doing. Three residents were asked about their care plans and were able to say that they can influence the care they receive. Staff were seen asking residents what they wanted. There is a form to record any contact residents have with doctors or other professionals. These showed that residents have contact with a variety of professionals including doctors, chiropodist, psychiatrist, district nurses and optician. The acting manager said that the clinical manager is responsible for ensuring arrangements are in place for meeting residents healthcare needs. Staff said they focus on residents needs and this makes meeting their healthcare needs fall into place, giving examples of eating well, having regular drinks, observing any changes in their behaviour and talking to them about how they are feeling. A member of staff described taking a resident to hospital who was not feeling very well. A resident said, “We ask to see the doctor if not feeling well” and “I have to wear my glasses all the time, staff make sure I am” There was a record made in the care file of medication reviews carried out and one care plan was seen which addressed how staff should react when a resident refused to take her medication. Part of the morning medication round was observed and the nurse was following the required safe practices in doing this. The nurse had slight differences in how she gave residents their medication and this was in line with their preferences. Ashley House Care Home DS0000024625.V354025.R01.S.doc Version 5.2 Page 13 The acting manager said that only the nurses give out medication and this was repeated by staff. A resident said, “I am given my tablets everyday”. Ashley House Care Home DS0000024625.V354025.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents need more opportunities to satisfy their social and recreational interests. Residents are helped to exercise choice and control over their lives and receive a wholesome and balanced diet. EVIDENCE: Staff were seen relating well with residents, taking time to speak to them and answer questions when asked. There was music on in the main lounge and residents were asked what they would like to listen to each time the disc was changed. There is an activities sheet in the care file however this was not being fully completed so there was not a clear picture of the level of activities provided. The acting manager said that activities was an area he had identified as needing to be improved and had identified some staff to do this. The acting manager said there are musical entertainers who regularly come to the home and this was confirmed by staff and a resident. Ashley House Care Home DS0000024625.V354025.R01.S.doc Version 5.2 Page 15 Staff said they organise an activity every afternoon for residents who are mobile with such things as snooker and magnetic darts. Staff showed a cupboard where a selection of games are kept and said they tell the duty nurse when they have organised an activity and who took part. Prior to some staff changes the duty nurse would then record the activity in the care file, however the system has not been reviewed since the staff changes and as a result a record of the activities taking place are not being made. The clinical manager said that she tapes a football programme over the weekend and brings it in for some of the residents to watch on Mondays. A resident showed the snooker table and said he liked to play. Another resident said, “I help the handyman everyday, it is better to be doing something”. The acting manager said some residents attend local clubs and community groups and the mobile library calls. Staff said they take residents to local shops to buy things such as wool, cigarettes and toiletries. One resident owns a dog and another resident likes to take the dog out for a walk. The resident was seen to do this. Two visitors were seen showing a resident an old photograph album and discussing this with him. The visitors said they are always made very welcome and can visit as often as they wish. The acting manager said that residents have opportunities to make choices around the food they have, what they watch and listen to, where they want to be, what they do and when they get up and go to bed. Staff said they give residents choices when assisting them and ask them what they want to do. A resident said he was not allowed out on his own which he wants to do, but agreed the reason for this had been explained to him and that the staff were being responsible in doing this. There is a three week menu in operation and the main meal is at lunchtime. Dishes include stew and dumplings, Cornish pasty, shepherds pie and quiche. There is a different type of fish on Fridays and a roast dinner on Wednesdays and Sundays. Residents can request an alternative if they wish. A lighter meal is had at tea time with such things as omelettes, ravioli and hot dogs. A pudding is provided at lunch and teatime. Ashley House Care Home DS0000024625.V354025.R01.S.doc Version 5.2 Page 16 Breakfast was observed and there were 19 bowls of the same cereal, with milk already added and a spoon in, on a trolley and these were being given to residents by a member of staff. The acting manager and staff spoken with said this is not normal practice and someone had done this to help as they were a member of staff short this morning due to unforeseen sickness, although cover was arranged later in the shift. It was agreed that this was not acceptable practice and the acting manager said he would ensure this does not happen again. A visitor said the food is very good and staff always spend time helping those residents who need assistance with feeding. A resident said, “The food is great”. Ashley House Care Home DS0000024625.V354025.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are systems in place for residents to raise complaints and protect residents from abuse. EVIDENCE: There was a copy of the complaints procedure displayed in the lounge area. There was a complaints log and this had one entry in since the last visit. This was from a relative who complained about the floor not being cleaned properly. This complaint was substantiated and as a result training has been arranged on use of cleaning materials and the floor polisher. The date for this was seen in the diary. There has also been one anonymous complaint referred to the home to investigate, which was received by The Commission for Social Care Inspection. This was concerning the number of hours staff were working, which was not substantiated and a lack of training, which was substantiated. The acting manager said there had been one recent complaint about the floor not being cleaned properly. Staff were also aware of this complaint and said it had been discussed in a staff meeting. Ashley House Care Home DS0000024625.V354025.R01.S.doc Version 5.2 Page 18 A resident said, “I will tell staff if I am not happy”. The acting manager said that there have not been any allegations of abuse made and that a copy of the new Adult Protection procedures have been received. The acting manager said he and the clinical manager are booked to go on a course about these and then share the information with staff in the next staff meeting. Staff said they have been trained on safeguarding adults and were aware that new procedures were now in use, and these are going to be discussed with them. A resident said, “Everyone is treated well” Ashley House Care Home DS0000024625.V354025.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents live in a safe, well-maintained environment, which is clean, pleasant and hygienic. EVIDENCE: The home is well laid out and has wide corridors and everywhere is accessible to wheelchair users. There is a choice of communal areas residents can use. The provider said that en suite facilities have been added to 7 rooms and a partition has been put into the large lounge. Staff said the building is well suited for caring for the residents and there is all the equipment they need. Ashley House Care Home DS0000024625.V354025.R01.S.doc Version 5.2 Page 20 A maintenance man is employed to carry out minor repairs and decorating and was seen carrying out various tasks including washing the windows. A resident said, “I have lived here for years and it’s my home”. There are cleaning staff employed to keep the home clean and tidy and areas of the home seen were in god order. Staff training records showed that training has been provided in infection control, and the acting manager said this is planned to be redone, as some staff are due for updates shortly. Staff said protective clothing is available and they were seen using this as they went about their duties. A resident said, “Its always clean here”. Ashley House Care Home DS0000024625.V354025.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are sufficient staff employed at the home, but they are not suitably trained. Residents are being placed at risk by the home’s recruitment procedures. EVIDENCE: The acting manager said he has assessed the minimum staffing levels to be 5 care staff and a nurse in the morning and afternoon and 2 care staff and a nurse overnight. In addition the home employs a clinical nurse manager, kitchen staff, handyman and housekeepers. One member of staff had not arrived for duty and other staff were contacted and asked to cover the shortfall, which happened. The home employs male and female staff and they are of varying ages and from differing ethnic backgrounds. Staff said that they were one short this morning due to someone calling in sick, but this had been covered by phoning another member of staff to come Ashley House Care Home DS0000024625.V354025.R01.S.doc Version 5.2 Page 22 in. Staff said this was unusual and there were normally enough staff to do the job properly. A visitor said there were always plenty of staff around to see to residents. A resident said, “I can always get a member of staff when I want one”. The staff training records showed that four staff have completed National Vocational Qualification level 2 and that two further care staff hold nursing qualifications. The acting manager said there are not any further staff due to study for this qualification but he will be arranging more in the future. The home has an induction programme and a copy of the induction check list was seen. A sample of two recently started staff files were seen and these did not have a Criminal Records Bureau or Protection of Vulnerable Adults check in. The acting manager said he had misunderstood the requirement for this to be obtained prior to staff starting work in the home. In addition the provider said he had not obtained a Criminal Records Bureau check on the acting manager prior to him submitting his application to become the registered manager. The provider and acting manager were referred to the Criminal Records Bureau website for the current guidance and reminded that this must be complied with. The staff training records showed that there were a number of gaps in staff training and some staff training was either out of date or close to being so. The acting manager said he recognised that there was a need to organise staff training in a number of areas. Staff said the are booked on a manual handling course later in the week and were due for fire training. Ashley House Care Home DS0000024625.V354025.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are some weak management systems in the home, which are placing residents at risk of abuse and harm. EVIDENCE: The acting manager, who is the son of the provider, has been working at the home for a year but has not yet submitted an application to become the registered manager. Then acting manager has a degree in business administration. Ashley House Care Home DS0000024625.V354025.R01.S.doc Version 5.2 Page 24 An audit survey was carried out in June 2007, which highlighted some areas of strength and others for improvement. This audit did not involve residents or relatives, and there is not a system for seeking residents’ views. There have been some survey forms sent out to seek views of relatives, however there only two returned. The home has a system for managing residents’ personal allowances and one record was looked at. This had not been updated since June 2007 and there was more cash than the record showed. The acting manager said that all the records had not been updated since June 2007 and that he had carried on receiving and giving out money on residents’ behalf. The acting manager said he has kept a record of what he has received and paid out at home and will be able to get the records correct. The home has a dog and cat and there were feeding bowls seen around the home. There has not been a risk assessment carried out on these animals being cared for in the home. Then fire log was seen and this had not been completed since July 2007. The handyman who is responsible for carrying out the fire tests said the tests had been done and that the previous clinical nurse had completed the fire record and he had not realised this was not being done now. Ashley House Care Home DS0000024625.V354025.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 1 X X 2 Ashley House Care Home DS0000024625.V354025.R01.S.doc Version 5.2 Page 26 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 OP1 Regulation 4(1) Requirement The Statement of Purpose and Service User Guide must be kept up to date and accurately reflect the services provided in the home so current and future residents know what they can expect Timescale for action 01/01/08 2. OP3 14(1)(a) Assessment documentation 01/01/08 should be amended to allow for information concerning residents’ ethnic origin and any significant relationship to be obtained. A record must be kept of all activities provided to show that residents are able to participate in frequent and varied activities, which are appropriate to their needs. Meals must be served in a manner that is appropriate and allows for residents’ choices and preferences. 01/01/08 3. OP12 16(2)(n) 4 OP15 16 (2)(i) 01/12/07 Ashley House Care Home DS0000024625.V354025.R01.S.doc Version 5.2 Page 27 5 OP29 19 (1)(a) The correct recruitment process must be followed at all times, including obtaining a Criminal Records Bureau check. THIS IS A REPEATED REQUIREMENT THE PREVIOUS TIMESCALE OF 01/03/07 HAS NOT BEEN COMPLIED WITH 19/11/07 6 OP30 18(1)(c) (i) Staff must be provided with the training they need to be able to do their work. This will ensure that residents are cared for by suitably trained staff. The proprietor must ensure that the manager in post applies to become the Registered Manager THIS IS A REPEATED REQUIREMENT THE PREVIOUS TIMESCALE OF 01/03/07 HAS NOT BEEN COMPLIED WITH 01/03/08 7 OP31 18(1)(a) 01/02/08 8 OP33 24 (1)(a) Residents must have opportunities to express their views on how the home is run. This will ensure that residents can have a say in how the home is run. A record must be made of every financial transaction, which is then signed and witnessed and a correct record held of the total amount of money held for each resident. A risk assessment should be in place regarding the care of the animals living in the home. A record must be made of all fire safety tests and checks that take place. 01/02/08 9 OP35 17(9)(a) 19/11/07 10 OP38 13(4)(a) 01/12/07 11 OP38 23(4)(a) 19/11/07 Ashley House Care Home DS0000024625.V354025.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ashley House Care Home DS0000024625.V354025.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ashley House Care Home DS0000024625.V354025.R01.S.doc Version 5.2 Page 30 - 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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