Inspection on 16/02/06 for Ashley Lodge

This inspection was carried out on 16th February 2006.

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

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

Other inspections for this house

Ashley Lodge 04/06/08

Ashley Lodge 05/06/07

Ashley Lodge 24/07/06

Ashley Lodge 20/09/05

Ashley Lodge 10/03/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Ashley Lodge Colmore Crescent Moseley Birmingham West Midlands B13 9SJ Lead Inspector Brenda O`Neill Unannounced Inspection 16th February 2006 09:45 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 Lodge DS0000063042.V282917.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 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 Lodge DS0000063042.V282917.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ashley Lodge Address Colmore Crescent Moseley Birmingham West Midlands B13 9SJ 0121 449 1503 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) Ashley Lodge RH Ltd Mrs Linda Joy Phillips Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Ashley Lodge DS0000063042.V282917.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That the registration category is 26 older people not falling within any other category. 26 (OP) Hot water restrictors valves to be fitted to all hot water outlets accessible to service users within 6 months of registration. All radiators to be risk assessed and guarded or replaced with LST radiators to reduce risks of scalding. All radiators in bathrooms and toilets and those near to beds or in restricted places will need to be guarded as a matter of priority. Within 3 months of registration for high risk radiators and six months for the remainder Window restrictors to be fitted to the side opening windows. The limit of the opening should be restricted to approximately 10 cms within 3 months of registration. The two external fire escapes to be refurbished and receive essential maintenance. The handrails on the fire escapes to have loose paint removed and be re-painted. The treads of the stairs to have the mildew removed. Doors leading onto the fire escapes to be alarmed in some way to alert staff that the doors have been opened. The door leading from the first floor landing onto the ‘back stairs’ to be attended to so that it closes properly into the rebate, the use of these stairs by service users to be risk assessed. Within 3 months of registration. Bedroom doors will to be fitted with suited locks which can be used by service users but enable access by staff in the event of an emergency within 12 months of registration. Bedrooms to be audited for furniture against the National Minimum Standards and arrangements made to provide items that are currently not in place. This is to include lockable item of furniture. Within 12 months of registration. Electrical sockets within service users bedrooms to be audited against the National Minimum Standards and additional sockets fitted as needed within 12 months of registration. Pipe work that is exposed in the bathrooms and along corridors to be boxed in within 6 months of registration. Requirements as identified in the homes own fire risk assessment (if any remain outstanding) to be addressed. Bedroom doors that have been identified as in need of door closure devices to have these fitted as per time-scales previously identified. Access into the ground floor bathroom which currently has a bath lift, to be reviewed. The step that needs to be negotiated cancels out some of the positive features of having a bath lift and it may be that the room currently used as a treatment room/store could be utilised as an assisted bathroom if a toilet was fitted and an alternative space for current use sought. Completion of review and submission of an action DS0000063042.V282917.R01.S.doc Version 5.1 Page 5 4. 5. 6. 7. 8. 9. 10. 11. Ashley Lodge plan within 3 months of registration. 12. 13. 14. 15. Permanent ramped access in to the home to be provided within 6 months of registration. The sluice sink which is located within a service user toilet to be removed and relocated or separated from the toilet within 6 months of registration. Two of the bedrooms are quite small and are below 9.3 square metres. Plans will need to be submitted advising how it is intended to extend these rooms within 12 months of registration. In addition to the manager and ancillary staff maintain minimum staffing levels of three care staff throughout the waking day and two care staff on night duty one of whom should be designated senior. 20th September 2005 Date of last inspection Brief Description of the Service: Ashley Lodge is a care home providing care and accommodation for 26 older people. The home is located about a mile from the centre of Moseley in Colmore Crescent, which surrounds St Agnes Church. There is a bus service that runs regularly into Birmingham and in the other direction to Hall Green that can be accessed by a ten-minute walk to the Wake Green Road. The area where the home is situated has a village feel and is about 5 miles from the centre of Birmingham. The home itself is situated in a grade 2 listed building and many of its original features remain. The home has well maintained grounds that can be viewed by the residents from the lounge areas. There is some car parking facility in the driveway of the home as well as the facility to park in the street, which had no restriction at the time of writing. The home has one double bedroom the rest of the residents having single bedrooms. All but two of the bedrooms have an ensuite toilet and wash hand basin. Some rooms have ensuite showers. The home has two assisted bathrooms. The home is on two floors with a shaft lift or spacious staircase to the first floor. Ashley Lodge DS0000063042.V282917.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day in February 2006 and was the second of the two statutory visits for the home for 2005/2006. To get a full over view of all the standards assessed during this inspection year this report should be read in conjunction with the report written following the inspection on September 20th 2005. During this visit a partial tour of the premises was carried out, three resident and two staff files were sampled as well as other care and health and safety documentation. The inspector spoke with the manager, deputy manager and five of the twenty five residents. What the service does well: What has improved since the last inspection? All residents were being issued with contracts at the point of admission to the home so that they were aware of the terms and conditions of their stay. The falls risk assessments for the residents had been further improved and detailed the equipment to be used by staff. Ashley Lodge DS0000063042.V282917.R01.S.doc Version 5.1 Page 7 The records of food being served to the residents had been further developed and evidenced that the diet was satisfactory in relation to nutrition and otherwise. The safeguarding of the residents had improved with all staff having undertaken training in adult protection issues and robust recruitment procedures being used by the manager. The levels of staff qualified to NVQ level 2 or the equivalent had improved and this was above the required 50 . The general safety of the residents had improved with the guarding of the radiators, hot pipe work being covered and all the requirements made by the fire officer had been met. Staff had also stopped administering insulin and this was now the responsibility of the district nurses. Some further improvements had been made for the comfort of the residents with more rooms being refurbished and having all the required furnishings and fittings. What they could do better: The manager needed to ensure that all care plans were updated regularly to reflect the current needs of the residents and that they were cross referenced to the monthly evaluations. All residents needed to have personal risk assessments that detailed the actions to be taken by staff to minimise any risks. The risk assessments needed to be updated as the needs of the residents changed. The manager needed to ensure that the induction training offered to staff covered all the areas detailed by Skills for Care and that it was completed within the first twelve weeks of employment. This would ensure all staff were equipped with the necessary skills and knowledge to fulfil their roles. The home needed a formal quality assurance system in the home based on seeking the views of the residents to ensure the quality of care being provided is in keeping with the aims and objectives of the home. Some improvements were needed to the environment to ensure it was accessible and that residents had all the aids and adaptations they needed. Ashley Lodge DS0000063042.V282917.R01.S.doc Version 5.1 Page 8 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 Lodge DS0000063042.V282917.R01.S.doc Version 5.1 Page 9 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 Lodge DS0000063042.V282917.R01.S.doc Version 5.1 Page 10 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): 1, 2, 3, 5 The assessment procedures in the home ensured the needs of the residents were known and could be met by staff. Prospective residents were able to visit the home prior to admission and were issued with a contract at the point of admission that detailed the terms and conditions of their stay. EVIDENCE: The statement of purpose for the home needed some minor additions in relation to the numbers of staff there were at the home. The room sizes had not been included in the document as there were ongoing changes to the rooms therefore it was agreed these could be added when all the changes were complete. Three resident files were sampled and all included evidence that the staff at the home had carried out a pre admission assessment that covered all the required areas. There was evidence on some files that the residents had visited the home prior to admission however it was strongly recommended that all pre admission visits were documented and an overview of the outcome of the visit included. There was evidence that all residents were issued with a contract at Ashley Lodge DS0000063042.V282917.R01.S.doc Version 5.1 Page 11 the point of admission to the home that included the terms and conditions of their stay. Ashley Lodge DS0000063042.V282917.R01.S.doc Version 5.1 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 The care planning system in the home was good but staff needed to ensure they were updated as the needs of the residents changed. Some improvements were needed to the risk assessments to ensure they were undertaken in a timely manner and reflected the current risks of the individuals. The medication system was generally well managed and safe with only minor requirements made. EVIDENCE: Three resident files were sampled, two for new admissions to the home and one for a resident who had been there a considerable length of time. All the files included care plans. There was evidence that either the resident or their representatives had been consulted about the care plans and they were generally well detailed. Areas covered in the care plans included nocturnal needs, mobility, personal hygiene, social and cultural needs and communication. The care plans included details of the individual’s likes and dislikes and their abilities. It was noted that one of the care plans had not been updated in all the necessary areas to reflect the deterioration of the general health of the resident. There was good detail in the monthly evaluations of the deterioration but this had not been cross referenced to the care plan in all instances. Ashley Lodge DS0000063042.V282917.R01.S.doc Version 5.1 Page 13 The files sampled included very detailed falls risk assessments which included all the actions staff were take in the event of a fall. These had been further developed since the last inspection and where the use of a hoist was detailed the sling size had been included. There were also manual handling risk assessments, nutritional screenings, tissue viability assessments and mental health assessments. It was noted that for the resident whose health had deteriorated that not all the assessments had been updated. Two of the files included personal risk assessments and the majority of these were well detailed and included specific actions to be taken by staff to minimise the risks identified. One of those sampled included the statement ‘use effective communication skills at a level she will understand’ this needed to be more specific and detail exactly how staff were to communicate. There were no personal risk assessments on one of the files sampled. This person had lived at the home for a month which was ample time to identify any specific risks. If no risks had been identified this should also have been documented. There was documented evidence that where staff had identified a health care need this was followed up and monitored. There was evidence of visits from G.P.s, district nurses, opticians and so on. Wherever possible residents were being weighed on a regular basis. Staff continued to administer medication via a 28 day monitored dosage system and this was generally well managed. Since the last inspection the audit trail for the homely remedies had been improved, controlled medication was being stored and recorded as administered appropriately and a specimen signature sheet was available detailing all the staff responsible for this. At this inspection it was noted that some controlled medication had been detailed in the controlled drug register as being returned to the pharmacist when it was still in the drug cabinet. This medication needed to be kept as part of the running balance until it was actually returned to the pharmacist to give a true reflection of what was actually in the home. The manager had contacted the doctor about PRN (as and when necessary) medication as to the dosage but there still needed to be specific written guidance for staff as to when they were to administer any PRN medication. Since the last inspection staff had stopped administering insulin and this was now the responsibility of the district nurses. Ashley Lodge DS0000063042.V282917.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 The food records seen demonstrated that residents received a varied and nutritious diet with choices available. EVIDENCE: Standards 12, 13 and 14 were assessed at the last inspection and found to be met. The residents spoken with were very satisfied with the catering arrangements at the home. The records of food served to the residents had been further developed since the last inspection and demonstrated that the residents were receiving a very varied diet that was nutritious with choices available. Special diets were being catered for including vegetarian and diabetic meals. The manager stated that the cook always joined the residents meetings to discuss the menus with the residents and that the outcome of the discussions were reflected on the menus. Ashley Lodge DS0000063042.V282917.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Staff had undertaken training in adult protection awareness ensuring they were equipped with the necessary skills and knowledge to be able to recognise and report appropriately any incidents or suspicions of abuse. EVIDENCE: Standards 16 and 18 were assessed at the last inspection and one requirement was made. This was in relation to staff training in relation to adult protection awareness and had been met. Ashley Lodge DS0000063042.V282917.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25, 26 The home offered residents clean, comfortable and generally spacious accommodation some issues needed to be addressed to ensure residents had adequate bathing facilities. EVIDENCE: The location and layout of the home were generally suitable for its stated purpose. Several conditions of registration had been imposed on the proprietor some of which had been met others had been partially met. Some areas of the home were in need of redecoration as paintwork was chipped and some areas looked a little shabby. The fire officer had made several requirements at the most recent visit to the home and all these had been met. The home had ample communal space with two lounge areas, a visitor’s lounge and a large dining room. Decoration was of an acceptable standard and it was proposed to replace some of the furnishings as the refurbishment of the home progressed. Ashley Lodge DS0000063042.V282917.R01.S.doc Version 5.1 Page 17 At the time of the inspection there was only one bathing facility in use on the ground floor as the one on the first floor was being converted into a floor level shower room. Access to the ground floor bathroom, which had a bath lift, was via a small step. The step cancelled out some of the positive features of having a bath lift and there were plans to extend this room, have the entrance resited so that there was no step and install a parker bath. The room currently being used as a treatment/store room was quite large and had a floor level shower and a sink and the manager discussed with the inspector having a toilet fitted in this room and using it as a shower room to give an additional facility. There were some aids and adaptations throughout the home including a small shaft lift, hand and grab rails, a freestanding hoist and wheelchairs. Additional handrails were needed along some of the corridors. There had been some difficulties with this due to the size of some of the radiators but these had now been covered and it was proposed to fit hand rails in between the covers. The front entrance of the home needed a fixed ramp however the proprietor had had to apply for planning permission for this, as the home was a listed building and was awaiting their response. A temporary, portable ramp was left in situ at all times. It was known by the inspector that two of the bedrooms were below 9.3 square metres and a condition of registration was that plans be submitted to the CSCI advising how these rooms would be extended. One of these rooms had been extended and the other had been taken out of use and was to be used as extra space/ensuite facilities for other rooms. The manager of the home had audited all the bedrooms to highlight any shortfalls in the furnishings and fittings as required in the conditions of registration. Some rooms had been refurbished and had all the required furnishings and fittings others were being done as they became vacant. As the refurbishment of the home progressed the proprietor was installing as many ensuite facilities as possible to improve the facilities for the residents. Since the last inspection all the radiators in the home had been guarded and the vast majority of the exposed hot pipe work had been covered. Measurements had been taken for the remaining pipe work and this was to be covered in the very near future. There were still some wash hand basins in the home that did not have thermostatic mixer valves fitted to the hot water outlet and this needed to be addressed. On the day of the inspection the home was clean and odour free. Ashley Lodge DS0000063042.V282917.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Appropriate staffing levels were being maintained by a stable staff group that could meet the needs of the residents. The recruitment procedures were robust and safeguarded the people living in the home. The manager needed to ensure all the required areas were covered in the induction training for staff to ensure they were equipped with all the necessary skills and knowledge to fulfil their roles. EVIDENCE: There had been very little staff turnover at the home since the last inspection and several of the staff had worked at the home for a considerable amount of time. The home was maintaining good staffing levels which were sometimes above the conditions of registration. The manager’s hours were supernumery to the rota and cooks and domestics were also employed. The residents spoken with were very positive in their comments about the staff team and friendly relationships were evident throughout the course of the inspection. The recruitment records for the two most recently employed staff members were sampled. Both files evidenced that POVA first checks had been undertaken prior to employment and CRB checks had been completed. All the other required documentation was on both files including, completed application forms and two references. The manager was also keeping copies of the interview notes. Ashley Lodge DS0000063042.V282917.R01.S.doc Version 5.1 Page 19 There was evidence that the two new staff had undertaken some induction training but the manager needed to ensure this was cross referenced to the specifications laid down by skills for care and that all the required areas were covered in the first twelve weeks of employment. Over 50 of the care assistants were qualified to NVQ level 2 and staff received ongoing training in a variety of topics, for example, adult protection awareness, food hygiene and manual handling. Ashley Lodge DS0000063042.V282917.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36, 37, 38 The manager ensured the smooth running of the home in a competent manner. The home needed a formal quality assurance system in the home based on seeking the views of the residents to ensure the quality of care being provided is in keeping with the aims and objectives of the home. EVIDENCE: The manager of the home had worked there for a considerable amount of time and was undertaking her Registered Manager’s Award. Throughout the course of the inspection she demonstrated a very good knowledge of the residents in her care and the running of a residential home. Discussions with both the manager and deputy manager evidenced how hard all the staff had been working to meet as many of the requirements made following the last inspection as possible. Ashley Lodge DS0000063042.V282917.R01.S.doc Version 5.1 Page 21 Throughout the course of the inspection it was evident there were good relationships between the manager and the residents and they were very comfortable in her presence. There was no formal quality assurance system in the home and the manager was aware of the requirement for this. There were regular resident and staff meetings and residents had their own notice board to keep them informed of what was happening in the home. There were also occasional resident and relative questionnaires to get their views on the home. The manager had developed a system of staff supervision and the appropriate areas were being covered. To ensure staff received the required six supervision sessions per year the manager was looking at delegating some of the supervision to other members of the senior staff. The service manager was a frequent visitor to the home and offered the manager support and assistance as needed. There were some copies of the monthly visit reports made by her but this were not consistent and some months were missing. Health and safety were generally well managed and improvements had been made since the last inspection, for example, all radiators had been guarded. There was evidence on site of the regular servicing and maintenance of all equipment, with the exception of the emergency call system, the water system had been checked for the prevention of legionella and all the in-house checks on the fire system were up to date. Accident and incident recording and reporting were appropriate. Ashley Lodge DS0000063042.V282917.R01.S.doc Version 5.1 Page 22 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 3 3 X 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 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 2 3 1 2 X 2 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X X 2 2 Ashley Lodge DS0000063042.V282917.R01.S.doc Version 5.1 Page 23 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)(c) Sch1(3, 16) 15(2)(b) 13(3)(c) Requirement The statement of purpose for the home must include the numbers of staff and the room sizes. Previous time scales of 01/05/05 and 31/12/05 not met. All care plans must be regularly updated to reflect the current needs of the residents. All residents must have personal risk assessments that include any actions to be taken by staff to the minimise risks. All personal risk assessments must be updated as the needs of the residents change. Previous time scale of 01/11/05 not met. There must be written guidance for staff to follow for the administration of PRN medication. Previous time scale of 14/10/05 not met. Any controlled medication in the home must be included in the balance in the drug register until it is returned to the pharmacist. All areas of the home must be DS0000063042.V282917.R01.S.doc Timescale for action 01/04/06 2. 3. OP7 OP7 01/04/06 01/04/06 4. OP9 13(2) 14/03/06 5. OP9 13(2) 14/03/06 6. OP19 23(2)(d) 01/03/06 Page 24 Ashley Lodge Version 5.1 7. OP19 23(2)(b) 8. OP21 23(2)(j) 9. OP22 23(2)(n) 10. OP22 23(2)(n) 11. OP24 16(2)(c) 12. OP24 16(2)(c) 13. OP24 12(4)(a) 14. OP25 13(4)(c) kept reasonably decorated. Previous time scale given had not expired. The window frame to room 19 must be repaired/replaced. Previous time scale of 01/12/05 not assessed for compliance at this inspection. Improvements must be made to the assisted bathing facilities and the availability of toilets in relation to the lounge areas. Previous time scales of 01/09/05 and 31/01/06 not met. Handrails must be fitted to both sides of the corridors wherever possible. Previous time scale of 01/12/05 not met. A permanent ramp must be installed to the main entrance of the home. Previous time scale of 31/12/05 not met. All bedrooms must be audited for furniture against the National Minimum Standards and arrangements made to provide items that are not currently in place. Previous time scale of 10/12/05 partially met. Electrical sockets within service users bedrooms must be audited against the National Minimum Standards and additional sockets fitted as needed. Previous time scale of 10/12/05 partially met. Bedroom doors must be fitted with locks, which can be used by service users but enable easy access, by staff in the event of an emergency. Previous time scale of 10/12/05 partially met. The remaining hot water outlets that do not have thermostatic DS0000063042.V282917.R01.S.doc 01/04/06 01/04/06 01/04/06 01/04/06 01/04/06 01/04/06 01/04/06 31/12/05 Page 25 Ashley Lodge Version 5.1 15. OP30 18(1)(a) 16. OP31 9(1)(b)(i) 17. OP33 24(1)(2) (3) 18. OP37 26 19. OP38 13(3) mixer valves fitted must be addressed and CSCI must be notified when this is completed. Previous time scale of 31/12/05 partially met. The manager must ensure that the induction training offered in the home covers all the topics and is completed within the time scales laid down by Skills for Care. Previous time scale of 31/12/05 not met. The manager must be qualified to NVQ level 4 in care and management. Previous time of 31/12/05 not met. The home must have effective quality assurance and quality monitoring systems in place, based on seeking the views of the residents. Copies of the monthly visit reports made by the representative of the company must be available for inspection. Previous time scale of 01/12/05 not met. There must be evidence on site that the emergency call system has been serviced. (Evidence that this had been completed was forwarded to the CSCI prior to the publication of this report.) 01/04/06 01/04/06 01/01/06 01/04/06 14/03/06 Ashley Lodge DS0000063042.V282917.R01.S.doc Version 5.1 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP5 Good Practice Recommendations It is strongly recommended that all pre admission visits to the home are recorded. Ashley Lodge DS0000063042.V282917.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Lodge DS0000063042.V282917.R01.S.doc Version 5.1 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!