Inspection on 07/06/06 for Ashlong House

This inspection was carried out on 7th June 2006.

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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashlong House 26/09/05

Ashlong House 28/04/05

Ashlong House 29/11/04

Ashlong House 17/06/04

Similar services:

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Whitworth Lodge

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

CARE HOME ADULTS 18-65 Ashlong House Ashlong House 141 Longfellow Road Worcester Park Surrey KT4 8BA Lead Inspector David Halliwell Key Unannounced Inspection 7th June 2006 09:30 Ashlong House DS0000048490.V292078.R01.S.doc Version 5.1 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 Ashlong House DS0000048490.V292078.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 Adults 18-65. 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. Ashlong House DS0000048490.V292078.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ashlong House Address Ashlong House 141 Longfellow Road Worcester Park Surrey KT4 8BA 020 8330 2708 01483 740 569 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) Throwleigh Lodge Jenny Hamilton Care Home 9 Category(ies) of Learning disability (9), Physical disability (4) registration, with number of places Ashlong House DS0000048490.V292078.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service user in bedroom 3 must be able to manage in the bedroom without the aid of a wheelchair. The service user who was named to the CSCI on 4th April 2005 is the only service user who may occupy Bedroom 2 if they require the use of a wheelchair whilst in the bedroom. 26th September 2005 Date of last inspection Brief Description of the Service: The home is a detached house situated in a cul-de-sac off a quiet street in Worcester Park. Ashlong House is registered to support 9 people with learning disabilities and physical disabilities. The home has been prepared so that the bedrooms, bathrooms and communal spaces can meet the needs of this service user group. Ashlong House DS0000048490.V292078.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The accumulated evidence used in this report came from a number of different sources, including the most recent CSCI inspection reports, information received from the providers which is held on the CSCI’s database, and information gathered from interviews with service users, staff and inspection of the Home’s records. The unannounced site visit to the home was carried out over 2 days on 7th & 8th June 2006. 3 Service Users and 3 staff members were interviewed during the visit including the homes Acting Manager. The Acting Manager was asked to complete the Equalities Survey and the rest of the site visit was spent examining the homes records and touring the premises. What the service does well: Overall the CSCI considers the Unit to be a good performing service that has far more strengths than weaknesses and one which provides the service users with a safe and happy environment in which to live. Service users met on the site visit said that they liked living at Ashlong House and generally viewed their time very positively. All three residents spoken with agreed that one of the best things about life at the home was the quality of the care and support they receive. They all feel at home living at Ashlong and one comment from a service user sums up the overall impression held by the Inspector, it was “ your own home is your own home where you should be able to make your own decisions and we can here…..this is home”. All staff met during the visit were observed interacting with the service users in an extremely friendly and respectful manner. Ashlong House DS0000048490.V292078.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: The Acting Manager has acknowledged that the service could do better in the service areas identified in this section of the report. Although service users may access copies held in the office it would represent a service improvement for service users if each service user was to receive their own copy of the Service User Guide. This should include a copy of the complaints procedure and process, a copy of their latest care plan and any relevant risk assessments. A signed and dated copy of their contract with the home should be included. A very ragged carpet in one of the residents bedrooms requires urgent replacement and this has been planned within the month. In terms of good practice with regard to care planning it has been recommended that referring agencies are kept within the care planning loop for their service users and that copies of “in house” reviews are routinely sent to the referring agency concerned for the resident. With reference to the quality assurance process the questionnaire for the service users should be revised and together with the input of a service user living in the home. The Acting Manager should analyse the feedback received from questionnaires and other feedback sources and where trends or themes emerge they are inputted in the home’s annual improvement plan as priorities for service improvements. Ashlong House DS0000048490.V292078.R01.S.doc Version 5.1 Page 7 That staff record in the daily record sheets all-important decisions and discussions had with service users as this will better protect service users and staff from misrepresentation at a later stage. Where ever possible notice should be provided to a service user as early as possible where planned events have to be changed. 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. Ashlong House DS0000048490.V292078.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashlong House DS0000048490.V292078.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 & 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is registered to provide support to people with learning disabilities and physical disabilities. Prospective service users and their representatives are provided with all the information they need to make an informed decision about whether or not to use the service. The home has a comprehensive admissions procedure that ensures that a thorough assessment of prospective service user’s needs and aspirations are carried out before they move in. Service users and prospective service users can be confident that their individual needs and aspirations will be appropriately assessed. EVIDENCE: The home has an appropriate Statement of Purpose and Service Users Guide which contains all the relevant information in an accessible style for the service users. However 3 service users interviewed during the course of this inspection informed the Inspector that they do not have their own copies of the Service User Guide although they can access the office copy. Copies of individual contracts were seen on each of the service user files inspected, they were however unsigned and not dated which is necessary. Ashlong House DS0000048490.V292078.R01.S.doc Version 5.1 Page 10 It is required that each service user receives a copy of the Service User Guide which includes a copy of the complaints procedure and process, their care plan, any relevant risk assessments and a copy of their contract with the home which is signed and dated. One new service user moved into the home on 10th October 2005. A review of service user files indicated that all service users have had their needs assessment carried out by a care manager prior to moving into the home and all have had their placements reviewed since moving into the home. The 3 service users who were interviewed supported this and confirmed their appropriate involvement in the review of their care plans. Ashlong House DS0000048490.V292078.R01.S.doc Version 5.1 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are involved in completing their own Life Style Plans and in their risk assessment reviews thus ensuring that their personal wishes and aspirations are considered. Service users are supported appropriately in taking risks as part of trying to achieve a more independent lifestyle. Service users plans inspected indicate that individual risk assessments and risk management strategies are carried out and monitored appropriately thus enabling service users to participate in activities in the home and in the community with appropriate support. EVIDENCE: Three service user files were inspected and all had a Life Style Plan, this plan is very comprehensive and includes detailed information on the service user’s health, social and domestic activities and communication needs. The plan is person centred and completed by the service user with help from an allocated key-worker. Plans examined included photographs of service users involved in Ashlong House DS0000048490.V292078.R01.S.doc Version 5.1 Page 12 domestic, therapeutic and social activities. The plan also includes information under the headings “The support I need to meet my needs and reach my goals” and “My daily living activities”. The acting manager said that these plans had been developed since new service users moved in. For a new resident the plans are reviewed initially on a three month basis and subsequently then on a six monthly basis. All service users have had their plans reviewed. In order to ensure that referring agencies are kept within the care planning loop for their service users it is recommended that copies of “in house” reviews are routinely sent to the referring agency concerned for the resident. The home offers service users and their relative’s questionnaires in order to seek their views of the service that the home provides. Information from these questionnaires is used as part of the homes Quality Monitoring System so that the service offered to the service users can be improved. Interviews the Inspector had with the service users identified that a review of the questions in the service user questionnaires is now required. This is in order to ensure that questions asked more thoroughly tests the quality of services offered to residents. It would be very useful if residents could be involved in this review of the questionnaire and 2 of the residents interviewed expressed an interest to the Inspector in taking part in this exercise. It is recommended that the Acting Manager analyses feedback received from questionnaires and other feedback sources and where trends or themes emerge they are inputted in the home’s annual improvement plan as priorities for service improvements. Service user meetings have in the past been a regular feature in this home however the Acting Manager informed the Inspector that residents had since decided they no longer wished to continue to have this type of meeting as their view is that it no longer met the purpose effectively. Interviews with 3 service users confirmed this view and all residents seemed much happier with raising issues with their key workers at their monthly meetings. Following a discussion the Inspector had with the Acting Manager it is recommended that staff record in the daily record sheets all important decisions and discussions had with service users as this will better protect service users and staff from misrepresentation at a later stage. All service users have had risk assessments carried out for both inside the home and for activities outside the home. These assessments are reviewed on a regular basis and are referred to in the service users care plans. All staff have signed the service users care plans. Ashlong House DS0000048490.V292078.R01.S.doc Version 5.1 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the 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, 15, 16 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Opportunities for the personal development of service users are appropriate and suitable to meet service user’s needs. Service users are able to take part in appropriate leisure and other activities some of which are part of the local community. Service users are also encouraged to maintain appropriate relationships. There is strong emphasis in the home on respecting resident’s rights in all aspects of daily living. The menu is varied, offers choice and provides a healthy enjoyable diet. EVIDENCE: Significant relationship links were recorded in those care plans seen by the Inspector and there was evidence that staff appropriately encourage the maintenance of these relationships if residents also wish to do so. Visitors to the home are encouraged and use the visitor’s book to sign in. Ashlong House DS0000048490.V292078.R01.S.doc Version 5.1 Page 14 Interviews with residents and staff identified that some residents are involved in local activities such as swimming, bowling, going to the cinema and to the pub, all of which assists service users in developing their social interactions and in their integration into the community. The acting Manager informed the Inspector that all residents are registered to vote in elections and are supported by staff to do so if the residents wish to. The Inspector saw information made available within the home about local activities for residents to take up if they wish. Some Service Users can and often do make full use of local public transport facilities in order to get out and about and to see friends and family. Interviews with 3 staff and with service users indicated that opportunities for the personal development of service users are very appropriate and that the views and preferences of service users are central to what is provided. Policies seen by the Inspector to be established within the unit ensure that service user’s rights to privacy, respect and dignity are respected. Residents who were interviewed also confirmed that they felt staff respected these rights. Residents said that their mail is unopened, staff uses their preferred form of address and staff do knock on their doors before entering. The Inspector observed staff to be interacting with residents in a friendly and respectful manner. A recommendation made at the last inspection for a discussion with all staff about the home’s policy on service user’s privacy has now been met. The Acting Manager informed the Inspector that all staff have seen, read and had a chance to discuss the unit’s policy. Other staff interviewed by the Inspector confirmed this. Interviews both with staff and residents confirmed that residents participate where appropriate in household chores as a part of the rehabilitative process and this participation was seen to be supported in residents care plans. There is a specific area for smokers and there are appropriate policies regarding drug and alcohol taking on the premises. With regards to meals and meal times there is a planned and varied menu which residents told the Inspector they thoroughly enjoyed. Where possible residents take an active part in planning and cooking their own meals and they are supported by staff to do so. Specific needs are catered for and alternative choices are provided. Ashlong House DS0000048490.V292078.R01.S.doc Version 5.1 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 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, 19 & 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users mostly receive personal support in the way they prefer and require. Overall the arrangements for meeting resident’s physical and health care needs of the service users are good. Service users are also protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: The home has policies and procedures for handling medicines and staff have had training on medication administration. All service users have been registered with a local General Practitioner and a local Dentist. One service user has been diagnosed with Aspergers Syndrome and all staff have had training on the subject. Another service user uses a Stoma and staff have received training in Stoma care. One service user has been diagnosed with presenting Pseudo Epileptic Seizures and there are guidelines for staff to follow in the event of this occurring. Ashlong House DS0000048490.V292078.R01.S.doc Version 5.1 Page 16 All the service users’ files inspected contained appointment information for dentists, opticians, chiropodists, weight charts and individual homely remedies. With reference to Service Users receiving personal support in the way they prefer, one Service User who was interviewed did express a wish for more advanced warning when planned activities have to be re arranged. On talking with the Acting Manager the need for this was acknowledged and it is recommended that where ever possible notice should be provided to a service user at least by the previous night as in most cases changes are known about by then. Ashlong House DS0000048490.V292078.R01.S.doc Version 5.1 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service user’s views are both listened to and acted upon. Service users are protected from abuse, neglect and self-harm by the policies and procedures of the home. EVIDENCE: All those service users interviewed by the Inspector confirmed that they feel their views are listened to and acted upon. They also all said that if they had a complaint they would know who to talk to however one resident was unsure of the procedure to be followed and that is why a requirement is made in the first section of this report. Staff interviewed confirmed to the Inspector that any issues raised by residents were taken seriously by the whole staff group. The home has an adult protection policy and the Acting Manager informed the Inspector that the whole staff group had received training in the last year. The allegation of abuse record was seen by the Inspector, no allegations had been made since the last inspection. This was confirmed by the Acting Manager to the Inspector. The policies and procedures manual for the home include a whistle blowing policy and a policy on dealing with violence and aggression. Understanding the policies and procedures is a part of the staff induction process and staff are asked to sign to say that they have read and understood the policies and procedures. A review of staffing records held on staff files by the Inspector Ashlong House DS0000048490.V292078.R01.S.doc Version 5.1 Page 18 confirmed that all staff had signed such an agreement. The Manager informed the Inspector that training in these areas is offered to staff. The home does look after resident’s money and the Inspector reviewed the financial records for these transactions which were in order. All transactions are dated and signed for by both staff and residents to confirm satisfaction by all parties. No anomalies were found by the Inspector. An inventory is maintained and kept up to date by key workers for all residents belongings which are kept in their bedrooms. Ashlong House DS0000048490.V292078.R01.S.doc Version 5.1 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users do live in a clean, hygienic, homely, safe and comfortable environment. EVIDENCE: The home supports service users with learning disabilities and physical disabilities. The home was assessed by an occupational therapist and the home has been built around the service users assessed needs. Most of the service users have en-suite facilities with either a bath or a shower as they have requested. Shower heads are set at assessed levels so that service users can use them. Service users with mobility problems have the use of hand rails and hoists. The kitchen work surfaces have been lowered and doors widened to aid service users who use wheelchairs. Some service users who have ceribal palsey have electronic door locks on their bedroom doors. Ashlong House DS0000048490.V292078.R01.S.doc Version 5.1 Page 20 The loose electrical earth wire under the sink area in the downstairs kitchen which was noted in the last inspection report has now been satisfactorily repaired. The wiring under the kitchen sink has been made secure and is now boxed in. This has reduced the risk of fire. Service users said that they have had the opportunity to choose furniture and decorate their own bedrooms, bathrooms and the living room. At the time of this Inspection a tour of the building was undertaken with the Acting Manager and all areas of the building were inspected. The home was clean and free of offensive odours on the day of the inspection however in one residents bedroom the floor carpet was badly damaged where the wheelchair had worn a large hole in the carpet. The need for this to rectified with a replacement carpet was acknowledged by the Acting Manager who assured the Inspector that a replacement is planned within the next month. This is a requirement. Ashlong House DS0000048490.V292078.R01.S.doc Version 5.1 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a well-supported staff team who receive the level of regular supervision and appropriate training required to ensure that the service users benefit from having a consistent approach to their needs. EVIDENCE: Inspection of staffing files identified that there are appropriate Criminal Records Bureau Checks for all staff. All members of staff are training or have trained for an NVQ qualification. One has completed NVQ level 2 in Care and one is completing an NVQ level 2. 9 are completing NVQ level 3 in Care. The Acting Manager is completing NVQ level 4. Training records indicate that staff have received training on first aid, fire safety, moving and handling, health and safety and food hygiene. There was evidence that staff have also had training on adult protection, epilepsy, medication and managing challenging behaviour. The Acting Manager said that there has been very little staff turnover in the last two years. Evidence was seen on staffing files that staff do receive regular supervision which covers all the essential elements of training and support as Ashlong House DS0000048490.V292078.R01.S.doc Version 5.1 Page 22 well as the monitoring of their work and its review. Inspection of the staffing files showed that staff have supervision contracts which is good practice and benefits both the Acting Manager and the staff alike. The Acting Manager informed the Inspector that she has implemented a weekly checklist of staff supervision to ensure that regular and appropriate supervision takes place and agreed actions are carried out. Ashlong House DS0000048490.V292078.R01.S.doc Version 5.1 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users do benefit from a very well run home and they can be confident that their views underpin the services the services that they receive in the home. The Inspector felt assured that the health, safety and welfare of Service Users are promoted and protected. EVIDENCE: The homes Acting Manager has achieved an NVQ level 3 and is near to completing an NVQ level 4 in management. She has acted as Deputy Manager in the home since January 2004 and has gained considerable experience from this and when speaking with the Inspector demonstrated extensive knowledge about the service users and the services being offered to them. From the positive interactions the Acting Manager had with service users and staff that Ashlong House DS0000048490.V292078.R01.S.doc Version 5.1 Page 24 the Inspector saw over the course of this inspection, she is clearly well thought of and liked by both groups of people. Interviews conducted by the Inspector with both staff and service users provided very positive feedback demonstrating the committed, sensitive and thoughtful approach the Acting Manager has and all of this means that the service users and staff benefit from a well lead and well run home. Monthly Regulation 26 visit reports have been sent to the Commission for Social Care Inspection as required. As previously stated in this report the home offers service user and their relative’s questionnaires in order to seek their views of the service that the home provides. While questionnaires for the service users is to be revised information from current questionnaires is used as part of the homes Quality Monitoring System so that the services offered to the service users can be improved. The home employs a full set of policies and procedures from the consultancy company Cared4. All these documents fully comply with the required standards as defined in appendix 2 of the National Minimum Standards. Certificates were seen for an environmental health visit 05/05/05, legionella testing 22/02/06, electrical appliances tested 03/06/06, Gas Safety Certificate on 2/02/06 and risk assessments undertaken for infection control 12/05. Fire records were examined, the fire alarm system was checked on 12/04/06, a fire risk assessment has been carried out for the home and a fire plan is in place and signed by staff. Fire evacuation drills are carried out quarterly by the home on the advice of the fire officer. Gaps previously noted on the recording of the weekly fire alarm system checks have now been rectified satisfactorily and the Acting Manager has ensured that the homes fire alarm system is checked and recorded on a regular weekly basis by a senior member of staff. This was confirmed by that member of staff who was interviwed by the Inspector and appropriate documentation was seen by the Inpector. Ashlong House DS0000048490.V292078.R01.S.doc Version 5.1 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 2 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Ashlong House DS0000048490.V292078.R01.S.doc Version 5.1 Page 26 Are there any outstanding requirements from the last inspection? No. 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 YA2 Regulation 5.2 Timescale for action That each service user receives a 09/07/06 copy of the Service User Guide which includes a copy of the complaints procedure and process, their care plan, any relevant risk assessments and a copy of their contract with the home which is signed and dated. A replacement carpet is required 09/06/06 for one service users bedroom. Requirement 2 YA25 23.2 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 YA10 Good Practice Recommendations In order to ensure that referring agencies are kept within the care-planning loop for their service users it is recommended that copies of “in house” reviews are routinely sent to the referring agency concerned for the resident. That the Manager analyses feedback received from questionnaires and other feedback sources and where trends or themes emerge they are inputted in the home’s annual improvement plan as priorities for service DS0000048490.V292078.R01.S.doc Version 5.1 Page 27 2 YA8 Ashlong House 3 YA10 4 YA18 improvements. That staff record in the daily record sheets all-important decisions and discussions had with service users as this will better protect service users and staff from misrepresentation at a later stage. That where ever possible notice should be provided to a service user at least by the previous night as in most cases changes are known about by then. 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