CARE HOMES FOR OLDER PEOPLE
Ashlodge Ashlodge 83 Cantelupe Road Bexhill on Sea East Sussex TN40 1PP Lead Inspector
Elaine Green Key Unannounced Inspection 22nd August 2006 10:00 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 Ashlodge DS0000041416.V295500.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. Ashlodge DS0000041416.V295500.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Ashlodge Address Ashlodge 83 Cantelupe Road Bexhill on Sea East Sussex TN40 1PP 01424 217070 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) Mr Balasingam Vijayakumar Mrs Kuhayini Vijayakumar Mrs Kuhayini Vijayakumar Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Ashlodge DS0000041416.V295500.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Service users must be older people aged sixty-five (65) years or over on admission. The maximum number of service users to be accommodated is sixteen (16). Date of last inspection Brief Description of the Service: Ashlodge is a detached property situated a short distance from Bexhill seafront, and a short walk from the town centre with its shops and access to bus and rail routes. Accommodation is provided on two floors with a passenger lift to provide access to first floor accommodation. All bedrooms are of single occupancy with en-suite facilities. Eleven bedrooms are on the first floor, whilst five are on the ground floor. There are three spacious communal lounges, a dining area and access to a well-kept rear garden. The home is registered to accommodate 16 older people. The Registered Providers are Mr and Mrs Vijayakumar who have owned the home since May 2003. Mrs Vijaykumar is the Registered Manager. The fees charged range from £305 - £352 per week depending on the size of the room occupied and care needs, which are assessed on an individual basis. Fees cover hotel costs and all ‘in house’ activities. Additional charges are made for an appointment with both the visiting Chiropodist and the hairdresser, charges for these services start from £10 per person. Ashlodge DS0000041416.V295500.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. As part of the Unannounced Inspection of Ashlodge a site visit took place to the home. This took place between 10:30 am and 3.30 pm on the 22nd August 2006. The Inspector had a tour of the building, joined service users in the dining room for their midday meal and had the opportunity to meet with a visiting relative and a visiting health care professional. The Inspector had discussions with the visitors, 4 service users, manager and members of staff team and their comments will be reflected within the report. A range of records and documentation were also examined and included some of the homes’ policies, procedures, guidelines and daily records, service users care plans, medication records and records pertaining to health and safety. The Commission for Social Care Inspection (CSCI) sent Service user questionnaires prior to the visit and feedback from the 9 completed questionnaires received will be included within the report. What the service does well: What has improved since the last inspection?
Since the last Inspection the providers have brought their statement of Purpose up to date and it now includes information relating to the manger and staff experience. A written procedure is now in place in relation to the ordering and checking in of medication into the home and the homes’ adult protection alerting procedure has been updated to ensure it is in line with local guidance.
Ashlodge DS0000041416.V295500.R01.S.doc Version 5.2 Page 6 Consultation has taken place with the service users in relation to the food provided in the home and improvements have been made to the dining room. The dining room has been decorated and is now much brighter and the tables and chairs have been replaced. The lounge area and two bedrooms have also been decorated. A number of magnetic closures have been fitted to fire doors throughout the home and the majority of radiators have had guards fitted to them. What they could do better:
There are a number of requirements that are outstanding from the previous Inspections and although some of these are nearly met it is important that the home ensures that they meet the timescales made within this report. Due to the number of outstanding requirements the manager is required to provide documentary evidence to the Commission for Social Care Inspection of their completion. Prospective service users must be provided with the documented information they need to make an informed decision about whether to reside in the home prior to them moving in. All service users including current residents must be provided with up to date copies of this information which must include a costed copy of their terms and conditions of residency. Improvements need to be made in relation to the detail contained in the preadmission assessment of service users including documentation of the assessment tools used. Currently care plans specify if support is needed but does not specify how this support is to be delivered. They must become more detailed and individualised and be reviewed and updated as and when required and a minimum of once a month. It is recommended that the manager delegate some of the responsibility for this to the staff team. The daily records contained in care plans are confusing, the manager needs to ensure consistency in relation to record keeping. Guidance is needed to be sought from service users’ General Practitioners in relation to when as and when medication can be administered. This requirement has now been made three times and has still not been met. The manager must also ensure that the homes, policies and procedures in relation to the administration of medication are followed at all times and that medication is administered in a timely way. Recruitment practices must improve with particular regard to ensuring that relevant and appropriate references are sought prior to employment and that their authenticity is checked. All staff employed by the home, including bank staff, must undergo a documented induction. The home must work towards ensuring that a minimum of 50 of the staff they employ hold a National Vocational Qualification (NVQ) in care at Level 2 or above. Several shortfalls of a serious nature were identified at this and previous Inspections in relation to the health and safety of the service users resident in the home. Requirements have been made in the past for automatic closures to be fitted to the fire doors through out the home. On the day of the site visit it
Ashlodge DS0000041416.V295500.R01.S.doc Version 5.2 Page 7 was noted that although some have been fitted to the doors of communal rooms, almost all bedroom doors were wedged or other wise propped open. An immediate requirement was left with the home for this practice to stop. The home is continuing their programme of fitting guards to the radiators in the home but has not completed the related risk assessments to those that remain unguarded. The manager must also ensure the home introduces a falls prevention policy and procedure that is individualised to the home. 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. Ashlodge DS0000041416.V295500.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 Ashlodge DS0000041416.V295500.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users pre admission assessments lack detail. Not all service users are provided with the documented information they require to make an informed decision about whether or not to reside there. EVIDENCE: The manager explained that when a prospective service user makes an enquiry they are invited to come and look at the room and the rest of the home. If the home is to their liking then the manager undertakes a preadmission assessment of the prospective service users needs. If the home can meet the service users needs then they invited to move into the home on a months’ trial basis. The homes’ Service User Guide and Statement of Purpose are left in service users rooms for when they move in. The Inspector spoke to service users about their experience of moving into the home and they confirmed that they had been able to come and have a look round and test drive the home before making a final decision and that they had been given a copy of the Homes’ Statement of Purpose and the Service Users Guide. Due to a change in legislation it is now required that the home makes the Statement of Purpose,
Ashlodge DS0000041416.V295500.R01.S.doc Version 5.2 Page 10 Service user Guide and a costed Statement of Terms and Conditions of residency/contract available to all prospective service users prior to them moving into the home. In addition to this a costed Statement of Terms and Conditions of Residency/Contract must be made available to all the service users currently resident in the home. Four service users pre-admission assessments were examined. While the assessments did cover those areas required by the National Minimum Standards for Older People they do not provide any detail of how, where or by whom the assessments have been carried out. It is important for this information to be included in the assessments and that all those involved in the assessment process sign and date the documentation, including the service user themselves. Where an assessment shows that an individuals’ mobility is poor the assessment should provide details of how the assessment was made and whether or not a formal assessment tool was used. The assessment should specify how current care needs are being met e.g. home help, district nurse, mobility aids etc. The pre assessment documentation should clearly demonstrate that the home has undertaken a robust assessment. Ashlodge DS0000041416.V295500.R01.S.doc Version 5.2 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users Care Plans are not sufficiently detailed to enable staff to support service users consistently and appropriatly. Service users health and care needs are met support is provided appropriately. Not all the homes’ medication policies and procedures are safe. EVIDENCE: Four care plans were examined. The care plans cover the areas specified by the National Minimum Standards for Older People they do not provide sufficient detail required in order for staff to deliver the care required consistently and appropriately. At the last Inspection a requirement was made in respect of adequately detailing the support required for an individual service user in respect of bathing. Although care plans now specify if individuals require assistance e.g. to bathe or with mobility, they do not specify what sort of assistance is required. The assistance needed by individuals varies enormously and so it is imperative that the care plans are accurate, up to date and individualised in order for staff to deliver the care and support that individuals’ need.
Ashlodge DS0000041416.V295500.R01.S.doc Version 5.2 Page 12 Currently the registered manager undertakes the task of writing reviewing and amending care plans and all the associated risk assessments. These should all be updated as and when required and reviewed a minimum of once a month. The care plans examined had not been reviewed as required, were not up to date and had not been signed and dated when written or reviewed. It is recommended that the manager consider delegating some of this responsibility to the care staff who work closely with the service users and who are aware of their changing needs. Care plans and daily records show that appropriate health care referrals are made when required and the manager explained that due to the deterioration of some service users health needs they had been reassessed and the home had been unable to continue to meet their needs. Staff were able to explain the actions they must take should a service user have a fall and were aware of the needs to carry out body checks and complete the relevant paper work. There are sections in the care plans for staff to record the activities that service users have participated in and the personal care that has been delivered. These records have only been completed spasmodically and some staff are recording this information on other daily records. It is important for this information to be readily available to those who may require it and the current systems are confusing and misleading. It is recommended that the manager reviews practice and procedure in respect of record keeping and takes steps to ensure consistency within the staff team. At the last Inspection it was highlighted that the home did not have a policy and procedure in relation to the prevention of falls. The manager has obtained some information in relation to this but the home still does not have policy and procedure in place that has been individualised to the home. On the day of the site visit the Inspector observed staff administering medication and examined the medication administration records. One service user was given their medication prior to the midday meal but did not take it until the meal was over. This was discussed with the manager who stated that this was the daily routine. It is required that medication should be given when it is going to be taken and that staff should, where possible observe the medication being taken. This will reduce the chance of mistakes being made and accidents happening. The medication administration sheets that were examined highlighted several errors that had not been identified. Some medication had not been signed for but had been given and one tablet was still in the packet but had been signed for. It is required that the manger ensures that the homes policies and procedures in relation to the administration of medication are followed at all times and that medication administration records are checked on a regular basis to identify any errors. It is also recommended that the home introduce a specimen signature sheet so that the person who has signed to say medication has been administered can be easily identified. At the last Inspection it required that guidance be sought from service users
Ashlodge DS0000041416.V295500.R01.S.doc Version 5.2 Page 13 GPs in respect of when ‘as and when’ medication could be administered. The manager has introduced some general guidelines but has not contacted GPs as required. Ashlodge DS0000041416.V295500.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service are provided with the opportunity to participate in appropriate leisure and social activities. The food provided is wholesome and nutritious. EVIDENCE: The Inspector had discussion with 5 service users, the manger and a member of staff in relation to the activities and entertainment on offer in the home. It appears that although activities and entertainment have been organised in the afternoon these sessions are not very well attended. The manager explained that she is in the process of reorganising these sessions at more convenient time for the service users. An examination of the activity timetable for the week illustrated that bingo, games and music were among the activities on offer. Several visitors were seen to come and go on the day of the site visit and 2 service users confirmed that their visitors often take them out. Another service user stated that staff assist her to go for a walk on occasions. Three service users spoke to the Inspector about the fact that they had choice in their lives and were able to get up and go to bed when they wanted to, choose whether or not to participate in activities, choose what they want to eat etc.
Ashlodge DS0000041416.V295500.R01.S.doc Version 5.2 Page 15 The Inspector joined service users for their midday meal in the dining room. The food was hot, home made and well presented. A choice was available and staff gave appropriate and timely assistance. An examination of the menu confirmed that a varied and balanced diet was provided and service users stated that the food was good. Many service users also stated that they have their breakfast in their rooms and enjoy this. Ashlodge DS0000041416.V295500.R01.S.doc Version 5.2 Page 16 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 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are protected by homes adult protection and policies and procedures and service feel they are listened to. EVIDENCE: At the last Inspection the home was required to amend their complaints policy and procedure, this was examined and had been amended as required. The manager explained to the Inspector that when service users had a complaint of any sort that they endeavour to sort things out efficiently and informally. It is recommended that a record is made of all such complaints including the action taken to rectify them. Service users stated that they would speak to the manager or a member of staff if there was something wrong and confirmed that they are listened to. There have been no adult protection alerts made in relation to the service users at Ashlodge and the senior member of staff on duty was aware of the procedures to follow should she suspect and incident of abuse had occurred. Ashlodge DS0000041416.V295500.R01.S.doc Version 5.2 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,25,26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable, homely, safe, well maintained and clean environment for service users to reside in. EVIDENCE: There have been improvements made to the decoration and furnishings provided in the home including the redecoration of the lounge, dining room and 2 bedrooms. The seating in the dining room has been replaced and the manager explained that she is waiting for the delivery of chairs to replace all those in the lounge. The home was clean and hygienic on the day of the site visit and the garden was well kempt and accessible. At the last 2 Inspections the home has been required to fit radiator guards to all radiators subject to a risk assessment. Although the manager explained that there was a programme in place to cove the remaining radiators and that they are being covered in order of priority, there were no risk assessments in place to support this.
Ashlodge DS0000041416.V295500.R01.S.doc Version 5.2 Page 18 Ashlodge DS0000041416.V295500.R01.S.doc Version 5.2 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users needs are met by the numbers and skills of the staff employed by the home. Not all the recuitment procedures adopted by the home are safe. Not all staff hold the relevant qualifications. EVIDENCE: The personnel and recruitment files were examined for four members of staff. The security checks had been completed for the three staff that had started work in the home and the manager was waiting for clearance for the fourth member of staff before she deployed her to work in the home as is required. In one of the recruitment files examined the member of staff had provided two references but these were from a colleague and a friend. References of this kind are not considered appropriate and further references must be sought from the individuals other current and previous employer. In addition to this one of the files examined only contained one form of identity where two are required. The manager and two members of staff explained that ‘in house’ inductions had been completed and that they had been shown around the home, introduced to the residents shown the fire exits and given time to read the service users care plans, however there was no documentary evidence to support this. The home has it’s own bank staff and it is important that these members of staff are inducted formally and that this process is fully documented. One member of staff stated she has had good training and an
Ashlodge DS0000041416.V295500.R01.S.doc Version 5.2 Page 20 examination of training records confirmed that the training provided meets the standards required and is delivered within the specified timescales. Not all staff are appropriately qualified however the manager explained that they are working towards meeting the target of 505 of their staff obtaining a National Vocational Qualification (NVQ) in Care at Level 2 or above. Feedback from service users surveys indicates that staff can usually answer their call bells quickly and that they don’t often have to wait long. Three members of staff stated that they felt there were enough staff on duty to meet the needs of the service sues currently resident in the home. An examination of the rota confirmed this. Ashlodge DS0000041416.V295500.R01.S.doc Version 5.2 Page 21 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service.The manager is appropriatly qualified and runs the home in the best interest of the service users who reside there. The health safety and wellfare of service users and staff in relation to the risk of fire is not protected and promoted. EVIDENCE: The manager is qualified and she is now registered with the Commission for Social Care Inspection (CSCI) as the Registered Manager. Residents spoke highly and positively of the management style and approachability of the manager. It was evident on the day of the site visit that good working relationships have been established between residents and staff. It was pleasing to note that active feedback form residents had been sought in respect of nutrition, communication, daily activities and the way in which care is delivered by way of a questionnaire.
Ashlodge DS0000041416.V295500.R01.S.doc Version 5.2 Page 22 The manager keeps small amounts of money for service users. This is used to pay for hairdressing, toiletries and outings. This money is kept securely and written records are kept of each transaction. A number of the homes’ health and safety checks and certificates were seen. It was pleasing to mote that all the certificates were up to date and that equipment is regularly maintained and serviced. Documents examined included the homes’ insurance certificate, boiler and heating system servicing records, fire equipment and emergency lighting maintenance and service records. Of concern is the fact hat despite previous requirements the home still had many fire doors wedged or other wise propped open throughout the home. This is extremely dangerous and poses a high risk to the service users in the event of fire. An immediate requirement was made for these wedges and props to be removed. Ashlodge DS0000041416.V295500.R01.S.doc Version 5.2 Page 23 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 3 2 2 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 2 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 1 Ashlodge DS0000041416.V295500.R01.S.doc Version 5.2 Page 24 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. Standard Regulation 1. OP2 (1b) Timescale for action That all prospective service users are 30/09/06 provided with a copy of the homes’ Statement of Purpose, Service User Guide and a statement of their terms and conditions of Residency/Contract prior to them moving into the home. All existing service users resident in the home must be also be given these documents if they do not already have them. Pre admission assessments must be 30/09/06 robust and detailed as specified in the report. All related documentation must be signed and dated appropriately. The manager of the home must 30/09/06 confirm in writing whether or not the home can meet the assessed needs of a prospective service user prior to them moving into the home. That guidance for staff to assist 30/10/06 residents with bathing is detailed within care plans. Outstanding from the last Inspection. Timescale 31/12/05 not met. Care plans must be individualised and clear guidance must be provided for staff to follow to support service users appropriately. They must be reviewed a minimum of
DS0000041416.V295500.R01.S.doc Version 5.2 Page 25 Requirement 2. OP3 14(1abcd) 3. OP3 14(1d) 5. OP7 12(1) Ashlodge 6. OP8 7. OP9 8. OP25 9. OP9 10. OP28 11. OP29 12. OP38 once a month and updated as and when required. 13(4)(a-c) That the home reviews its falls procedure and implements risk assessments for the prevention of falls. These must be in accordance with guidelines produced by the Department of Health (NICE) Not fully met outstanding from the last Inspection timescale 31 January 06 not met. 13(2) That the homes’ policies and 17(1a) procedures in relation to the sch 3 (k) administration of medication are consistently followed with particular regard to ensuring that medication is administered in a timely manner and that medication records are accurate, complete and checked on a regular basis. 13(4ac) That all radiators assessed as posing a high risk to residents are guarded. This is outstanding from the last 3 Inspections timescale 31 March 06 not met. 13(2) That advice is sought from residents’ Sch2 prescribing General Practitioner’s regarding the use of PRN (as and when required) medication. This must be clearly documented. This is outstanding from the last Inspection. Timescale 31/12/05 not met. 18(1abc) That 50 of the care staff employed by the home obtain an NVQ in Care at level 2 or above. 19(1) That thorough recruitment checks are Sch2 carried out for all new and existing staff. The authenticity of references must be checked. This is outstanding from the last Inspection. Timescale 24/12/05 not met. Appropriate references must be sought. 23(4a) That automatic fire door closures are fitted throughout the home in accordance with the recommendations made by the Fire Safety Officer. This
DS0000041416.V295500.R01.S.doc 30/10/06 30/09/06 30/12/06 30/10/06 30/12/06 30/10/06 31/10/06 Ashlodge Version 5.2 Page 26 13. OP38 23(4a) is outstanding from the last two reports. Timescale 31/03/06 not met. An immediate requirement was made 22/08/06 for all wedges and props to be removed from all fire doors throughout the home and for the practice of using wedges and props on fire doors to stop. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP7 OP7 OP16 Good Practice Recommendations That the manager considers delegating some of the responsibility to the staff team in relation to reviewing and updating care plans. That the manager reviews the practice and procedures in relation to service users daily records. It is recommended that a record is made of informal complaints specifying the action taken to rectify them. Ashlodge DS0000041416.V295500.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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