Inspection on 23/08/07 for Ashlodge

This inspection was carried out on 23rd August 2007.

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

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

Other inspections for this house

Ashlodge 22/08/06

Ashlodge 24/11/05

Ashlodge 16/05/05

Ashlodge 27/11/04

Ashlodge 25/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Ashlodge 83/85 Cantelupe Road Bexhill on Sea East Sussex TN40 1PP Lead Inspector Lucy Green Key Unannounced Inspection 10:50 23 & 30th August 2007 rd 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.V345588.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.V345588.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashlodge Address 83/85 Cantelupe Road Bexhill on Sea East Sussex TN40 1PP 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) 01424 217070 01424 217070 kuha@btinternet.com 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.V345588.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). 22nd August 2006 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 £325 - £370 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.V345588.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report reflects a key inspection based on the collation of information received since the last inspection and a site visit which lasted for a total of four hours. The inspection was conducted across two days, with the first visit being unannounced. The Registered Manager was not available on the first day of inspection and therefore the Inspector arranged to return a few days later to look at some documentation and meet with the Registered Manager. During the site visit, the Inspector conducted a partial tour of the premises on both days and undertook an examination of some medication, care and staffing records. The Inspector met with eight of the thirteen residents accommodated at the time of the inspection. Two staff, including a carer and a member of agency staff were interviewed as part of the inspection. Comment cards were sent to the home to distribute amongst relatives and visitors. At the time of this report, seven had been returned to the CSCI. The Inspector had a telephone conversation with a visitor during the visit. What the service does well: Ashlodge is a family owned and run home and employs a stable and committed team of staff. The home is situated in an attractive location and offers a homely environment for residents to live in. Residents benefit from their own bedrooms with ensuite facilities and a choice of comfortable communal and private spaces to spend their time. Ashlodge is a relaxed and friendly home where residents receive care in a respectful and dignified manner. Positive comments from residents were expressed throughout the inspection, including “this is the loveliest, happiest home” and “I couldn’t fault the home”. Residents benefit from a choice of freshly prepared meals each day. On the second day of the inspection the lunch was observed being served and found to be well presented and residents spoken with were complimentary about the food they had received. Residents have the opportunity to spend their time as they choose. The home encourages and supports people to be as independent as possible and to maintain contact with family, friends and the wider community. Ashlodge DS0000041416.V345588.R01.S.doc Version 5.2 Page 6 All the feedback received from relatives and visitors is extremely positive about the home. One relative commented that Ashlodge :offers love and care and a genuine concern when asking the residents how they are”. Similarly, another relative stated that staff “are giving [resident] such a happy life. She loves it there, and she always thinks of it as her home”. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ashlodge DS0000041416.V345588.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashlodge DS0000041416.V345588.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 & 6 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 benefit from key information about the services provided at Ashlodge being made available to them. Prospective residents are protected by an assessment process that ensures their needs are identified and confirmed they can be met before they move into the home. Ashlodge does not provide intermediate care. EVIDENCE: It was a requirement of the last inspection that the home ensure that all current and prospective residents receive a copy of the home’s Statement of Purpose, Service User Guide and a statement of the terms and conditions relating to their residency at Ashlodge. The Registered Manager provided documentary evidence that the Statement of Purpose and Service User Guide had been updated since the last inspection and confirmed that current and Ashlodge DS0000041416.V345588.R01.S.doc Version 5.2 Page 9 respective residents now receive copies of this information. Copies of signed contracts were found in the two care plans viewed. Discussion with residents and feedback provided from relatives’ surveys indicated that residents and their representatives had received sufficient information about the services at Ashlodge to help them in making decisions about which home to choose. Information submitted by the Provider in the Annual Quality Assurance Assessment detailed that there have been four people admitted to Ashlodge in the last twelve months. The Inspector viewed the pre-admission assessments information in place for two of these people. There was documentary evidence that a representative from the home had conducted an assessment on each individual prior to both these residents moving into the home. The home had also obtained copies of other relevant information and assessments for these individuals. The Registered Manager showed the Inspector a new template that she would be using when conducting future pre-admission assessments. This template was more noted to be more detailed than the one that has been utilised to date and therefore its introduction should represent a further improvement in this area. A review of the subsequent care plans in place for these two individuals provided evidence that the information gathered at the assessment stage is then subsequently used to develop a plan of care. Prospective residents are encouraged to visit the home prior to admission to assess the suitability of the placement. There was evidence in care plans and from speaking with the individuals, that the residents recently admitted to Ashlodge had visited the home, or their representative had visited, prior to them moving in. In both cases the home had also confirmed in writing to the individual that the home could meet the individual’s needs for a permanent stay. There is no provision for intermediate care at Ashlodge and therefore Standard 6 is not applicable. Ashlodge DS0000041416.V345588.R01.S.doc Version 5.2 Page 10 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 & 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 and personal care needs are met in a respectful and private way. Residents are protected by the systems in place to manage medication. EVIDENCE: A sample of three care plans were viewed and it was evident that a large amount of work has been undertaken to improve these documents. Each resident now has a plan of care that provides detailed information about their health and welfare needs. The overview of care needs which provides the reader with instant key information about the type of support each resident requires makes the care plans easy to use. Care plans contain risk assessments for a range of areas and it is generally possible to track the level of risk and the controls in place to minimise the risk. The home is however reminded to ensure that adequate risk assessments are in place for all activities and issues where a potential risk is posed, including Ashlodge DS0000041416.V345588.R01.S.doc Version 5.2 Page 11 for those residents who access the community independently. The home must ensure that the judgements they make instinctively are robustly recorded. There was evidence that care plans and associated documentation are now reviewed on a monthly basis and any changes made recorded. Staff practices observed throughout the inspection days demonstrated that they have a good understanding of the residents and their needs. Discussion with staff produced evidence that they have a good knowledge about the people they support. Residents are encouraged to lead their lives as they choose and it was entirely obvious that staff provide support in the way preferred by each individual. It was clear from observation, talking to residents and staff and from the written material in place, that care and support is provided in a sensitive, dignified and respectful way. Throughout both inspection days, staff were noticed knocking on residents’ doors and seeking permission before entering their private space. Residents are fully supported with their health care needs and care plans contain a record of any visits or contact with professionals external to the home. There was evidence of current involvement from General Practitioners, District Nurses, Speech & Language Therapists, Chiropodists and Opticians. Records demonstrated that residents are regularly weighed and dietician input is sought where necessary. Nutritional screening was found to be undertaken periodically. In line with a requirement from the last inspection, the home has introduced falls risk assessments which are completed following a fall and then reviewed on a monthly basis. Medication systems were inspected by way of a review of the Medication Administration Records (MAR sheets) and examination of the storage of medication. The supplying pharmacy undertakes routine checks of medication and it was evident that any recommendations from these visits have been actioned. The home has a good system in place for managing medication. Records were clear and it was possible to track changes of medication. It was a requirement of the last inspection that advice is sought from residents’ prescribing General Practitioners’ regarding the use of PRN medication. The Registered Manager reported that she had experienced some difficulty on obtaining this information from the Doctors. It was therefore suggested that she contact the supplying pharmacy for advice and update residents’ guidelines accordingly. The Registered Manager confirmed that only staff who have been appropriately trained and supervised handle medication. Ashlodge DS0000041416.V345588.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 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 are supported to lead their lives how they choose. Residents benefit from an inclusive environment and receive choice and flexibility at mealtimes. Further improvement could be made by increased opportunities for activities and social outings. EVIDENCE: The daily running of the home was observed on both days to allow residents the freedom of choice about when they get up and go to bed. During the inspection it was noticed that residents choose where and how to spend their time. Conversations with residents highlighted that they have each developed their own individual routines and wherever possible, staff facilitate this. Residents are encouraged and supported to maintain contact with their family and friends. The home operates an open door policy and residents are able to spend time with their guests in their rooms or in one of the lounges. Feedback Ashlodge DS0000041416.V345588.R01.S.doc Version 5.2 Page 13 from visitors was they are made to feel welcome; “there is always a welcome towards us” and “at Ashlodge there is always a welcome”. Discussion with residents, staff and management highlighted that the home does provide some opportunity for residents to engage in activities. On the second day on inspection, a number of residents were observed to be engaged in a game of bingo. Other reported activities included; manicures, weekly communion and church visits and singers who visit on a 6-8 weekly basis. One resident also attends a blind club each week. Discussion with residents identified that staff sometimes support residents to go out for walks to the nearby seafront. Others go out with friends or family. Whilst the majority of residents indicated that they like to do their own thing and did not necessarily want to participate in structured activities, there was some feedback presented from residents and relatives that the home would benefit from increased opportunities for social inclusion. One relative stated “I think there is a need for some social stimulation” and another stated in response to question about suggesting improvements at the home “more activities”. The provision of meals continues to be of high quality. Meals are prepared according to a four-week rotating menu, with residents, staff and management confirming that an alternative is always available. There was evidence that specialist diets are catered for and one resident had their own menu. The serving of the lunchtime meal was observed on the second inspection day, with the choices being either gammon, swede, courgette and mashed potato or sausages and mashed potato. Dessert was lemon meringue pie and ice cream. Residents are able to choose where to take their meals, but for many this is seen as a social time. The dining room is arranged into small groups and lots of positive interaction was noticed at this time. The food seen was appetising and nicely presented and all residents spoken with spoke highly of the food provided at Ashlodge. One resident told the Inspector; “the food is good and well cooked”, with another commenting “you get an excellent choice, you can’t fault it”. Ashlodge DS0000041416.V345588.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 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. Residents benefit from an open culture where they are able to express their views and feel valued and protected from harm. EVIDENCE: Ashlodge has a complaints policy which is accessible to both residents and visitors to the home. In line with a recommendation made at the last inspection, the home has introduced a complaints book. It was noted that four minor issues had been logged and satisfactorily dealt with. The CSCI has not received any complaints about the provision of service at Ashlodge in the last twelve months. The residents spoken with all confirmed that they knew how to complain and stated that if they had any concerns they would speak with the Manager or a member of staff. Feedback from visitors also reflected that they knew how to raise concerns. Residents are protected by the systems in place to manage their money and the home ensures that staff are employed subject to appropriate recruitment checks. Ashlodge DS0000041416.V345588.R01.S.doc Version 5.2 Page 15 The staff interviewed were knowledgeable about the vulnerability of residents and the systems in place to protect them. The Registered Manager has purchased a training video on the protection of vulnerable adults and currently three staff have watched the video and answered the test questions. This is to be extended to the rest of the staff team in due course. It highlighted to the Registered Manager that she should obtain a copy of the latest local multiagency guidelines for the safeguarding of vulnerable adults. Ashlodge DS0000041416.V345588.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 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 continue to benefit from the comfortable, clean, accessible and homely environment provided at Ashlodge. EVIDENCE: Ashlodge is an attractive, detached property near the seafront in Bexhill-onSea. The home provides level access throughout by way of a passenger lift and series of ramps. Residents are accommodated in single rooms, with ensuite facilities. Communal space offers residents a range of places where they can meet with other residents and/or their visitors. There is a well-maintained and attractive garden to the rear of the home. Parking is available outside the front entrance. Ashlodge DS0000041416.V345588.R01.S.doc Version 5.2 Page 17 In line with a requirement from the last inspection, the Registered Manager confirmed that all high risk radiators have now been fitted with guards and that appropriate fire safety devices have now been fitted to those doors that were previously found to be propped open. The home employs domestic staff to ensure the home is kept clean and tidy. The home was found to be clean, hygienic and free from any offensive odour. Feedback from residents and visitors alike confirmed that the home is always maintained to a high standard. Ashlodge DS0000041416.V345588.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 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 benefit from being supported by a kind and dedicated team of staff and are protected by the recruitment systems in place. Further protection would however be afforded if the home could demonstrate a greater commitment to staff training. EVIDENCE: A review of current and past rotas indicated that staffing levels provide a minimum of three care staff across the waking day. The Registered Manager works in a supernumerary capacity. At night, the home is staffed by one waking staff member. In addition to care staff the home employs adequate numbers of cooking and domestic staff. The Registered Manager and staff spoken with all confirmed that staffing levels were adequate at this time. Feedback from some relatives indicated that they felt staffing levels could be increased. Whilst there were no concerns about the adequacy of staffing levels on either of the inspection days, the Registered Manager is recommended to keep this under review, in line with changing needs. Ashlodge DS0000041416.V345588.R01.S.doc Version 5.2 Page 19 The residents who spoke with the Inspector again commented how nice staff were. One resident expressed, “the staff are very good, excellent” and another commented, “staff are very kind and thoughtful”. The Registered Manager confirmed that new staff undergo an induction programme that is in line with Skills for Care. It was a requirement of the last inspection that a t least 50 of staff complete National Vocational Qualifications (NVQ) in Care to at least level 2. The Registered Manager explained that there had been some difficulty in meeting this target, as staff were reluctant to complete this qualification. Many of the staff at Ashlodge are from oversees and have undertaken a host of relevant training in their home countries. Whilst this is acknowledged, the home has a legal duty to meet workforce targets and therefore this needs to be addressed. The home has a training programme in place and staff have recently completed training in fire, protection of vulnerable adults, medication, infection control and manual handling. The training plan for September includes first aid and health and safety. There has only been one new member of staff employed since the last inspection. The recruitment files for this individual was inspected and the required information was in place for each individual, including satisfactory checks with the Criminal Records Bureau, two written references, completed application form and full employment history. On the second day of inspection, a member of agency staff was on duty. The Inspector interviewed this person and it was confirmed that they had received a basic induction at the home before staring on shift. This included being shown around the home and explained the fire procedure. They were also introduced to the residents and given a basic overview of their care needs. Ashlodge DS0000041416.V345588.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 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 benefit from living in a home that is well managed and run for their best interests. The home must develop formal systems for quality assurance in order to continuously improve service delivery. EVIDENCE: The home provided evidence that Ashlodge is run in the best interests of the people who live at the home. The Registered Manager has recently completed the Registered Manager’s Award. Staff and residents spoke highly of the management of the home. One resident told the Inspector that the Providers are “ever so nice”. Ashlodge DS0000041416.V345588.R01.S.doc Version 5.2 Page 21 The home has an open and inclusive environment where people feel valued and listened to. That being said however, the home must develop more formal systems for monitoring quality assurance. Whilst the home does undertake a periodic survey of residents’ views, it was discussed with the Registered Manager that the home needs to develop more formal systems of self-audit and gaining feedback, in order that the home can continuously improve. Residents’ finances are safeguarded by a system that ensures all transactions are logged and receipts maintained. The information submitted to the Commission by way of the Annual Quality Assurance Assessment indicates that the home has a number of systems in place to ensure the health and safety of the home is monitored and maintained. The Inspector did not therefore look at records pertaining to the maintenance of equipment and routine testing, although it was highlighted that safety checks on portable appliances should be undertaken annually. Ashlodge DS0000041416.V345588.R01.S.doc Version 5.2 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 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 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 2 3 X X X X X X 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 3 X 2 X 3 X X 3 Ashlodge DS0000041416.V345588.R01.S.doc Version 5.2 Page 23 YES Are there any outstanding requirements from the last inspection? 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 OP6 Regulation 13(4) Requirement The Registered Manager must ensure that risk assessments are undertaken in respect of all areas of residents’ lives where that are at potential risk of harm. The Registered Manager must ensure that advice is sought from residents’ prescribing General Practitioner’s regarding the use of PRN (as and when required) medication. This must be clearly documented. Timescale for action 01/11/07 2. OP9 13(2) Sch2 01/11/07 3. OP28 18(1abc) (Previous timescales of 31/12/05 and 30/10/06 not met) The Registered Manager must 01/01/08 ensure that 50 of the care staff employed by the home obtain an NVQ in Care at level 2 or above. (Previous timescale of 30/12/06 not met) The Registered Manager must implement a formal system of monitoring quality assurance. The Registered Manager must ensure that portable appliance DS0000041416.V345588.R01.S.doc 4. 5. OP33 OP38 24 13(4) 01/12/07 01/11/07 Ashlodge Version 5.2 Page 24 safety tests are conducted on an annual basis. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP12 OP18 Good Practice Recommendations The Registered Person should regularly consult with residents about the range of activities available in the home. The Registered Person should obtain a copy of the local multi-agency policies and procedures for safeguarding adults. Ashlodge DS0000041416.V345588.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Ashlodge DS0000041416.V345588.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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