Inspection on 02/05/08 for Ashlyn

This inspection was carried out on 2nd May 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ashlyn 27/04/09

Ashlyn 22/08/06

Ashlyn 03/11/05

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Ashlyn Vicarage Wood Harlow Essex CM20 3HD Lead Inspector Sharon Thomas Unannounced Inspection 1st May 2008 09:00 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 Ashlyn DS0000062965.V363833.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. Ashlyn DS0000062965.V363833.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashlyn Address Vicarage Wood Harlow Essex CM20 3HD 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) 01279 868330 01279 868332 julie.cox@excelcareholdings.com Ashlyn Healthcare Ltd Mrs Julie Cox Care Home 60 Category(ies) of Dementia (31), Old age, not falling within any registration, with number other category (60) of places Ashlyn DS0000062965.V363833.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Dementia - Code DE The maximum number of service users who can be accommodated is 60 22nd August 2006 2. Date of last inspection Brief Description of the Service: Ashlyn is a care home owned by Excelcare Holdings PLC. It is located approximately 2 miles from the centre of Harlow but is within walking distance of shops, and local amenities. Ashlyn is a purpose built home that provides residential accommodation for 60 older people with low to high dependency needs, 31 of who have Dementia. The home provides personal care to those service users who have been assessed as needing this. The home aims to provide 24-hour individual care and is successful in meeting the physical, emotional and social needs of the service users who live there. The home has bedrooms located on both the ground and first floor; the upper floor of the house is accessible to all residents through the passenger shaft lift. The home is well decorated and offers a homely atmosphere to the individuals living there. The homes bed rates range between £437.71 and £478.59. Ashlyn DS0000062965.V363833.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This unannounced key inspection visit took place on both the 1st and 2nd May over a total of 7 hours. We visited the home looked at some paperwork and important documents, we had a look at the home and how it is decorated and if it is homely and comfortable. We spoke with the people living in the home and had some discussion with the manager and staff. 21 of the 38 National minimum Standards and the intended outcomes for these were assessed at this visit and all but one were met. The manager of the service was on duty of the day of the visit and she spent a lot of the time with the inspector helping to gather the information that was needed. This report has been written using evidence gathered prior to and during the inspection. A sample of staff and residents’ records and important paperwork was looked at together with direct and indirect observation. Since the previous visit the home has opened the upper floor specialist dementia unit. The unit was homely, calm and comfortable. The manager has stated that a great deal of the home’s resources went in to the opening of the unit and that this has been identified as a probable cause of the increase in the number of complaints received from individuals. The manager and area manager hope that this situation is now resolved and that the resources are now balanced in all areas of the home. On the day of the inspector’s visit the atmosphere in the home was relaxed and welcoming. People living in the home made many positive comments throughout the day and were happy with the care that they get. People living in Ashlyn have a range of care needs, some people are very independent, mobile and need little or no supervision with their care whilst others need assistance with walking and their personal care and every day tasks. Staff are trained to provide care for the range of people living in the home. Throughout the day it was evident that the manager has taken on the majority of responsibilities in the home and she admitted that she found it difficult to delegate tasks to senior staff. What the service does well: Ashlyn DS0000062965.V363833.R01.S.doc Version 5.2 Page 6 People living in the home and their relatives are complimentary about the environment and the care provided. One relative said, “Service is good” and someone living in the home said, “This home is a very nice home to live”. Overall Ashlyn provides a clean, homely environment and is generally well maintained and decorated. The menu in the home provides people with a well-balanced and varied diet. Staff provide good home cooked food that is enjoyed by people living in the home. Before moving into the home people’s needs are well assessed and they are involved in the decisions about how staff give them the care they need. Interactions between staff and people in the home are caring and professional. Staff are able to provide support for people in a way that meets their needs and wishes and it was noted that individuals are encouraged by staff to say how they wish to be looked after. The manager and staff make sure the personal and healthcare needs of people living in the home are met and relevant healthcare professionals are consulted where appropriate. People are treated individually and the manager is able to demonstrate a good awareness of individual needs, wishes and preferences. What has improved since the last inspection? What they could do better: Record keeping and risk assessments are not well organised and records do not reflect or support the good standard of care provided by the service. The service must ensure that people’s dependency needs are continuously assessed and that staff numbers match the needs of those living there, particular attention is to be paid to the residential unit. The manager and staff must ensure that infection control procedures are followed at all times. Staff must ensure that unpleasant odours in the home are minimised. Staff are to be supervised on a regular basis to ensure that continuous staff development is achieved this is to include annual staff appraisals. The manager’s AQAA should be developed to ensure that the information that we at the commission receive accurately reflects the care that is provided. Ashlyn DS0000062965.V363833.R01.S.doc Version 5.2 Page 7 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. Ashlyn DS0000062965.V363833.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 Ashlyn DS0000062965.V363833.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People choosing to live at Ashlyn can be confident they will receive appropriate information about the home, and that their needs will be assessed before admission. EVIDENCE: Four sets of paperwork belonging to the newest people choosing to live in the home were examined on the day of the inspection visit. A pre-assessment form is used by the home and a qualified member of staff will carry out an assessment of that persons need. Additionally, if an individual is referred by a social worker the home will make sure that it receives a social service assessment before going out to visit the person in their home or setting. If all parties agree to the admission the person will be offered a trial visit, have a key worker allocated to them, have a four-week trail period and then a review. Part of this review will include the individual, their social worker Ashlyn DS0000062965.V363833.R01.S.doc Version 5.2 Page 10 or any relatives and representatives they may choose to have there to see if the home is suitable for them and can cater for their needs. The manager confirmed that “all residents have pre-admission assessments”, the sample of four care plans that we examined all had pre-admission assessments in place, which had been undertaken by the manager/deputy. The assessments are in a ‘tick box’ format, but cover a range of needs including the person’s physical health, dependency needs, mental health and social needs. The manager is able to demonstrate a detailed knowledge of people’s needs and abilities. Three members of staff spoken with also displayed a good awareness of people’s assessed needs. The manager’s AQAA states: A well planned Activity programme. On going staff training. Good choice of menu. Working closely with Social Services to ensure no one is made permantly untill they are happy. Offer trial visits, extensive service user guide issued to residents and relatives on admission. At any point an interim meeting will be held. Families told of any health visits, hospital appointments and families in formed of any falls etc Ashlyn does not provide intermediate care, although emergency short-term placements are considered. Ashlyn DS0000062965.V363833.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall needs. protect privacy people’s care plans contain the information required to meet their Health care needs are met and medication policies and procedures people. People are treated with respect and their dignity and their is upheld. EVIDENCE: From a sample of records examined, we could see that the information in the pre-admission assessments is reflected in people’s care plans. The areas covered include, safe environment, communication, hygiene, dressing / undressing and mobilising. All care plans had a risk assessment in place and two of these needed to be updated to include all of the risks that the individual may experience. Care plans do not on the whole describe the person’s strengths and abilities and this may result in staff’ doing things for people and undermining the person’s ability to carry out tasks for themselves. The care plans have improved since the previous visit and work needs to continue to make sure that care plans contain all of the information about the individual Ashlyn DS0000062965.V363833.R01.S.doc Version 5.2 Page 12 and direct staff on how to care for them. This will result in the staff having up to date information that will allow them to give the care that the person needs in a way that they want it. Staff spoken with, including the deputy manager, were able to demonstrate a good knowledge of the individual needs of people living in the home. We saw evidence of two care plans having been signed by the individuals indicating that they are involved in the care planning process. In the care plans we found comprehensive information and good direction for staff. However, the information was not well organised and therefore difficult for staff to follow, this could have the effect of information not being read or found and care not being provided in the way that it should. The manager’s AQAA states: Liase with out side agencies, such as GPs, District Nurses, Dietician etc. Liase with families and service users. Staff being inducted on sills to care. Staff currently on an indepth Dementia course with Chelmsford college. Staff completing and new staff starting NVQ level 2, including Domestic assistants. People spoken with were positive about the care they receive and our observations confirm that people appear happy, well looked after and are well dressed and groomed. Someone in the home who completed a survey some months before this inspection visit said, “I have lived here for more than a year and I am very well looked after” another said they receive “good care”. Two relatives spoken with commented that the home was “very good” and “my relative is very well cared for I have no complaints about the care they receive”. Medication used in the home is stored within lockable trolleys and stored securely. Controlled drugs are being maintained in accordance with procedures. Sheets that record the administration of medication are up to date and accurate with clear recording of what was given signed by a trained member of staff, therefore people in the home are protected from error. Staff administering medication in the home have been given proper training. Observations on the day of the inspection confirm that staff are kind and courteous and treat people with respect. Staff spoken with demonstrate a positive attitude and care for the people they are working for. Staff said to the inspector what respect and dignity meant in a care setting and they are fully committed to this aspect of care. People spoken with said …”the staff are very gentle and caring” and …”they always treat me with respect and have time for me”. One of the relatives spoken with said, “the care staff have a hard job looking after people and despite this they never show any impatience”. We saw some incidents where staff were not able to attend to people as soon as they asked for assistance. Staff on the lower floor were very busy during the inspection visit and were not able to attend to people’s needs immediately. This issue was raised with the manager and area manager and it was agreed Ashlyn DS0000062965.V363833.R01.S.doc Version 5.2 Page 13 that there may be a need for additional staff and that the area manager would re-calculate the levels of dependency of the people living in the home. Ashlyn DS0000062965.V363833.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in Ashlyn have opportunities to maintain a lifestyle that suits their needs and wishes. The home provides people with a well-balanced and nutritious diet with choices that meet individual need. EVIDENCE: The activity programme offered in Ashlyn provides a variety of social activity that is suitable to the needs of the people living there. Specific activities to address the needs of people with dementia are provided, and the activity programme is balanced between people living in the residential side of the home and those people with dementia. The care plans that we looked at had some detail regarding the social and leisure needs and wishes of individuals. Staff were observed talking with the people who live in the home and spending time with them. Overall the atmosphere in the home is calm with people sitting in lounges and occupying themselves quietly. There was an opportunity for them to join in activities during the day if they chose to. People confirmed that they sometimes have the option of going out to the local area if they want to however, during the day of the inspection they were content to stay at home. Ashlyn DS0000062965.V363833.R01.S.doc Version 5.2 Page 15 People living in Ashlyn said that the home’s activity co-ordinator provides a variety of activities in line with what they enjoy doing. One person said, …“I like watching other people playing the games” …”I prefer not to do the things that they do but I like the bingo ”, one relative commented …”my [Mum] has lots of things to keep her occupied and she seems to enjoy herself” while another said “I feel that there is not enough choice of structured activities for people in the dementia unit”. In one kitchenette two people were washing up and tidying up the immediate area. The staff on duty are aware of the social needs of the people in their care. People living in the home say that their relatives can visit at any time, and they can meet with them in the privacy in their bedrooms. The home arranges a weekly church service and representatives of other faiths attended the home as requested. Peoples’ rooms were well personalised, showing that people could bring their own possessions into the home with them. All rooms had locks and people were able to have keys to their room should they wish. People spoken with said they were enabled choices in their daily lives (e.g. time in getting up, going to bed, where and what they ate etc.) The home provides a varied and nutritional menu with fresh fruit and vegetables provided each day. The main meal served on the day of the inspection looked appetising and people said that the meals served in the home were tasty and of a high quality. Liquidised food was provided for people who had difficulty swallowing/chewing. Hot and cold drinks were seen being served during the day. The menu of the day was observed displayed on the notice board in a dining room. The chef said that he meets with people to determine their choices and obtains feedback on how they have enjoyed the meals. The chef and the assistant take a great deal of pride in the food that they cook and have achieved industry awards for their efforts. Relatives and individuals who completed surveys said “we have good food”; “I like the food”; “they will accommodate snacks at time suitable to people”. The kitchen was clean and well organised with appropriate cleaning schedules in place that were adhered to. We found that in one dining room the breakfast crockery was still on the tables at 11:00am as staff were busy undertaking other tasks. The managers AQAA states: We have an in-depth activities programme to suit individual service user needs that includes regular church services, communion and fortnightly film shows. We have a Pat dog/cat and regular outside entertainer’s visits. We have meetings monthly audits and quality assurance surveys and combine them to an action plan. All staff have the opportunity to enrol in NVQ 2. Ashlyn DS0000062965.V363833.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. If people have concerns about the care they receive, they or others know how to complain. Any concern is looked into and action is taken to put things right. The manager and staff safeguard people from abuse and take the correct action if an allegation is made. EVIDENCE: In the lead up to this visit the CSCI had received four complaints regarding the home. We reviewed the way that the home responded to these complaints and we were satisfied that the manager reacted promptly and properly to the complaints that they were aware of. The complaint log was looked at and we saw that the home have received seven complaints since the previous inspection. The staff had recorded the complaint, the action taken in response to the information and the overall outcome to the complaint. Many of these, it was noted were made at the time of the opening of the new unit in the home. The manager agreed that this had been a busy time when perhaps issues may have been overlooked she welcomed the complaints and felt that she has responded appropriately. The manager has a set of policy and procedures for safeguarding vulnerable adults and a whistle blowing procedure for staff to use. The records confirmed that all care staff with exception of two had received training in protection of vulnerable adults. From discussion with the manager, deputy manager and staff it was evident that any allegations of abuse made to staff would be Ashlyn DS0000062965.V363833.R01.S.doc Version 5.2 Page 17 referred to the appropriate agencies and the relevant procedures would be followed. There have been two allegations of abuse made since the previous inspection and these were dealt with in a professional and timely manner. The manager’s AQAA states: All complaints are followed up and outside agency input to assist in ensuring service users needs are met. Relatives updated throughout and any concerns or issues dealt with. Ashlyn DS0000062965.V363833.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in Ashlyn benefit from an environment that meets their needs and provides a homely and welcoming place to live. EVIDENCE: The manager’s AQAA states: The home has a relaxed and happy environment, visitors are made welcome. Facilities to make hot drinks are available for visitors. During a tour of the premises we saw that furnishings are domestic and comfortable and that overall people living in the home benefit from very homely surroundings. Bedrooms are individual and show evidence of personal possessions such as ornaments and photographs. The part of the home where Ashlyn DS0000062965.V363833.R01.S.doc Version 5.2 Page 19 people with dementia live have been cleverly decorated with pictures, advertising boards and memorabilia from the past. Some room have an issue with odour and the manager and a relative stated that when this is identified the domestic staff do as much as possible to eliminate it. One room in particular needs to have the carpet removed and non-slip washable flooring to replace it. The home is well decorated throughout and the standard of hygiene is good. Laundry facilities are well maintained and staff spoken with demonstrated a sound knowledge and understanding around infection control and issues. Documentation showed that staff have inflection control training and that all health and safety equipment, protective clothing is available for staff to enable them to protect both the health safety and welfare of themselves and of the people who live there. One relative spoken to said that they had previously had occasion to complain about some cleanliness issues, but felt satisfied that things improved after that. On the day of the inspection, two red bags were found in the communal hallway, and were lying open on the floor; this resulted in presenting an infection control hazard. The manager was advised of this and promptly dealt with the issue. Ashlyn DS0000062965.V363833.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in Ashlyn benefit from a competent, well trained staff team who receive appropriate supervision. The recruitment procedure in the home provides the safeguards that makes sure that appropriate staff are employed. EVIDENCE: Three members of staff spoken with were positive about working at Ashlyn. One person said, “working here is rewarding, it is a really friendly home. There are good relationships between staff” and “the manager is good but she always very busy”, this statement was reflected on what we saw during the visit and things said by other people. It became clear that the manager takes on too much responsibility and finds it difficult to delegate tasks to other senior staff. This issue was discussed with both the manager and the area manager and it was agreed that the organisation would support the manager to resolve the issue. The manager’s AQAA does not include enough information regarding staffing levels. Ashlyn DS0000062965.V363833.R01.S.doc Version 5.2 Page 21 The recruitment process used in the home is thorough. The personnel files of three recently employed staff were inspected. Both had evidence that the required checks had been obtained (two satisfactory references, CRB/POVA checks) and copies of birth certificates, passports, and photographs obtained before the individuals commenced employment at the home. All had received a statement of terms and conditions of employment. Staff spoken with confirmed that they were unable to start work until all of the checks had been made. The manager’s AQAA states: Intense induction programme. We currently are not using agency staff and now have a full compliment of staffing levels. One person who had previously completed a survey said, “I find any help and advice which I want is given” and a relative stated, “I can’t fault the care given to the residents at Ashlyn. The staff are always friendly and helpful”. People visiting the home were highly complimentary about the staff team. The manager’s AQAA states that the home does not meet the National Minimum Standard of having 50 with National Vocational Qualification (NVQ) at level 2 or above. The manager said that out of a total of 53 care staff 11 have completed the NVQ Level 2 while 25 members of staff are enrolled on the course. The sample of personnel records examined contain evidence of NVQ awards. The staff training programme confirms that all staff have received training around the Protection of Vulnerable Adults. Staff training certificates are kept in personnel files. Records examined confirm that staff have received training in dementia, death, medication, pressure sore management and continence. The manager said that dementia training is ongoing. Staff spoken with were able to demonstrate a good knowledge of their responsibilities and ensuring they follow good practices. Observations on the day of the inspection also confirm that staff carry out their roles in a caring and professional manner. Overall people living in Ashlyn benefit from being cared for by a competent staff team. The staff spoken with and the manager confirmed that supervision is not taking place on a regular basis. The manager confirmed that this is an issue that is being developed and she will ensure that staff receive supervision on a regular basis. Ashlyn DS0000062965.V363833.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall Ashlyn is well managed and run in the best interests of the people who live there. The health and safety of individuals living and working there is promoted and protected. EVIDENCE: Records examined confirm that the manager is suitably qualified to run the home. She has a National Vocational Qualification at Level 4 in care and has obtained the Registered Manager’s Award (RMA). The manager has been through the registration process with us at the Commission since the previous inspection. We saw evidence that she undertakes a variety of training to keep her knowledge up to date and she is keen to take up any training that will enhance her skills. Ashlyn DS0000062965.V363833.R01.S.doc Version 5.2 Page 23 Completed surveys from people using the service are complimentary about the way the home is run. A relative said, the “New manager is good and lovely with the clients” and a resident stated, the “Manager is very good”. All people living in the home have a representative to manage their finances on their behalf and some managed their finances with assistance of a relative. The home had secure facilities for the storage of any money looked after on their behalf. The personal monies of four residents were inspected and found to be correct with records and receipts held. The home has an established quality assurance process that gathers and uses people and their relative’s viewpoints as key information, professionals and staff are also surveyed to find out information regarding their views on how the home is run. A variety of issues are looked at, the information gathered and used to implement changes where necessary. The organisation produces an annual published report and we at the commission receive a copy. Records relating to maintenance of equipment such as lifts, fire equipment and electrical supplies were examined and are accurate and up to date. The service provides health and safety training as part of the annual training planned for each member of staff and the staff are aware of their responsibilities in maintaining the health and safety of themselves, their colleagues and the people living in and visiting the home. The manager’s AQAA states: New monitoring systems being implemented and tasks being delegated. Full staff recruitment. No agency currently being used. Audits, reports internal and external being combined into 1 action plan and ongoing to resolved. Ashlyn DS0000062965.V363833.R01.S.doc Version 5.2 Page 24 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 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Ashlyn DS0000062965.V363833.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 14 (1) Requirement Timescale for action 31/07/08 2 OP7 13 (a) (2) 3 OP27 13 (4) Care plans must contain enough up to date information to ensure that staff can deliver the proper care to people. Care plans must contain up to 31/07/08 date and accurate risk assessments that reflect the needs of the person and reduce the risk to their person. People living in the home must 31/07/08 benefit from having enough staff on duty to ensure that their needs are met. 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 OP18 Good Practice Recommendations The home’s complaint policy and procedure should be user friendly and are in a format that is easy to read and understand. Ashlyn DS0000062965.V363833.R01.S.doc Version 5.2 Page 26 2. 3 OP26 OP31 The home must maintain effective infection control procedures and should ensure that the smell of odour in some bedrooms are minimised. The manager should ensure that sufficient information is contained in their annual quality assurance assessment. Ashlyn DS0000062965.V363833.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. 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