Inspection on 20/02/07 for Ashville Care Home

This inspection was carried out on 20th February 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 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

Ashville Care Home 20/01/10

Ashville Care Home 09/02/09

Ashville Care Home 13/01/06

Ashville Care Home 30/06/05

Ashville Care Home 04/02/05

Ashville Care Home 20/07/04

Ashville Care Home 16/03/04

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

CARE HOMES FOR OLDER PEOPLE Ashville Care Home 58 Town Lane Idle Bradford BD10 8PN Lead Inspector Karen Westhead Key Unannounced Inspection 20th February 2007 09:15 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 Ashville Care Home DS0000049481.V327028.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. Ashville Care Home DS0000049481.V327028.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashville Care Home Address 58 Town Lane Idle Bradford BD10 8PN 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) 01274 613442 01274 618273 Ashville Care Home Limited Mrs Donna Ruth Brown Care Home 29 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (4), of places Physical disability over 65 years of age (10) Ashville Care Home DS0000049481.V327028.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th January 2006 Brief Description of the Service: Ashville Care Home is in Idle, an area about three miles from Bradford City Centre. The building used to be a wool merchants house. The original house has had a number of extensions. It is registered to provide care for up to twenty-nine older people. Fifteen residents within this number may have a diagnosis of dementia and ten may have a physical disability. The owners are consulting with relatives and residents about altering the registration, so that they can look after more people with dementia. They are also discussing this proposal with the Commission for Social Care Inspection (CSCI). The business was sold, when the previous owner retired last year. It was bought by Kimberley Malcolm in May 2006 and is still a Limited Company. The home has also appointed a new manager who was registered recently. This was again due to the retirement of the previous manager. The home is just off the main road and is well served by public transport. There is car parking to the front of the property. There is level access to the main door of the home and a stair lift is fitted to allow residents and/or their relatives with mobility problems to reach the bedrooms located on the first floor of the building. All the communal areas used by the residents are on the ground floor of the home. There are three lounge areas and one main dining room. There are 23 single and 3 double bedrooms. Fifteen of the single and all three of the double rooms have ensuite facilities (a toilet and large hand wash basin.) There are three communal bathrooms and toilets, which are within reach of bedrooms and lounges. On 16 January 2007 the fee was confirmed as between £380 and £420 per week. Additional charges are made for hairdressing, private chiropody treatment, reflexology, taxi fares and magazines if purchased by individuals and not provided by the home. Ashville Care Home DS0000049481.V327028.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was done by one inspector and had not been prearranged with the Manager. This meant the inspector was able to observe how the home is run on a day-to-day basis, without any changes being made to the usual routines of residents and staff. The inspector arrived at 9.15am and left at 4.45pm. At the end of the visit, the manager was told how well the home was being run and what needed to be done to make sure the home meets the required standards. The reason for the visit was to make sure the home was being run for the benefit and well being of the residents and in line with the standards. Before the inspection information received about the home was reviewed. This included looking at the number of reported incidents and accidents, the action plan provided following the last inspection and reports from other agencies such as the fire safety officer’s report. This information was used to plan the inspection visit. The fact the new owners bought the business following the last inspection was taken into account. A number of records were looked at during the visit; and nearly all areas of the home were seen. The inspector also spoke to residents, visitors and staff. CSCI comment cards were left at the home for relatives and visitors to complete. At the time of writing this report none had been returned. Therefore only the verbal feedback from residents is included in this report. Part of the day was spent talking to residents and staff, to find out what it is like to live and work at Ashville. Where residents weren’t able to give a view, the inspector watched how staff interacted with residents and did their work and how residents responded to this. What the service does well: Ashville is a friendly home with a relaxed atmosphere. Staff focus on the residents welfare and the standards of the care they provide. The new owners and manager have worked hard to bring the home up to the required standard and they have a clear vision and plan about what they want to do to make Ashville a better place to live. All residents are assessed prior to coming to live in the home and staff have a good insight into what care they can provide. The manager and staff are proud of the care they deliver. They want residents to see Ashville ‘as their home’ and take their duty of care seriously. Ashville Care Home DS0000049481.V327028.R01.S.doc Version 5.2 Page 6 Staff took an interest in the residents they were caring for and were knowledgeable, competent and the manager was prepared to accept suggestions for improvement. Residents, who were able to share their experiences, did see Ashville as their home and they talked positively about their surroundings and the staff looking after them. There was evidence that residents could keep using their skills, independence and feeling of usefulness. Staff were seen to give assistance without denying the resident the right to try for themselves. Parts of the building and facilities are good. The manager agreed there is still work to be done, but this has been planned and will be carried out at a reasonable and understandable rate. A number of requirements have been made but this should not overshadow what is a pleasant and comfortable environment for residents. 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. Ashville Care Home DS0000049481.V327028.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 Ashville Care Home DS0000049481.V327028.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): 1, 3, 4 and 5 (6 N/A) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives have enough information about the home to decide if it will meet their needs. EVIDENCE: The Statement of Purpose and Service User Guide provides enough information for residents and their relatives to make an informed choice about whether they think Ashville might be a suitable home. The staff on duty thought these could be produced in larger print on request, for those with poor sight. The documents describe what the home provides, what is not included in the fees, and informs people about the admission process. Four files were looked at including the most recently admitted resident. Three of the residents had had an assessment before being admitted to make sure Ashville Care Home DS0000049481.V327028.R01.S.doc Version 5.2 Page 9 the home could meet their care needs. One resident had been admitted on an emergency basis and it had not been possible for a preadmission assessment to be carried out. However, staff had worked with the family to gain as much information as they could to make sure the resident settled. All residents were reissued with new contracts when the new owners took over. Three examples were seen where representatives of relatives had signed the contract on behalf of the resident. The contract has been written using plain language and sets out what the fee is, what the resident can expect for that fee and the terms and conditions of their stay. Ashville Care Home DS0000049481.V327028.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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents care needs are met but the plans of care are not accurate and do not contain risk assessments. Therefore mistakes could be made which might compromise resident’s care. EVIDENCE: Four files were looked at including the most recently admitted resident. Overall, the information seen gave some insight into the needs of the person but more work is needed to make sure the record is accurate and shows changes in care needs, how this is followed up and what action is being taken. For example where residents had lost weight, there had been no nutritional assessment carried out or a risk assessment which showed the level of risk and what staff should do to minimise this. Care plans were not being reviewed monthly; therefore any changes in care delivery were not being recorded and were not up to date. Blank records gave the impression that there had been an omission in recording whereas the resident may well have been offered an Ashville Care Home DS0000049481.V327028.R01.S.doc Version 5.2 Page 11 opportunity to engage in an activity for example and had refused. One resident was being aggressive towards staff and other residents. This was said in the daily notes but had not been picked up as a risk. Therefore no plan had been written on how best to deal with this and the action being taken to refer the matter to a specialist or other professional. The manager said that they had recently changed the care plans to the new standardised format and staff were just becoming familiar with the new system. This was taking time. It is expected that there is an entry on a residents daily records at least twice a day by the day and night staff. The manager talked about the care provided at Ashville and there are clear boundaries with which the home operates. For example, when they are no longer able to give the level of care needed they know when to consult other professionals and if necessary assist the resident and their family to find an alternative home. This would be used as a last resort. If resident’s needs could be met in the home using other resources, for example the district nurses or advocacy then this would be tried. Medication is dealt with correctly. There are two drug trolleys, which are kept locked inside a secure cupboard. Only staff trained to give out medication do so. The drugs held were checked alongside the record sheets, and apart from one minor error, were accurate. None of the current residents deal with their own medication. There are routine reviews of medication and staff were knowledgeable about what medication was held and what it was being used for. There is an agreement with the resident’s doctor which home remedies can be used if required. Residents are seen in private when the doctor visits. Staff accompany residents to give the doctor up to date information regarding their conditions and to discuss any changes in medication or treatment. There was evidence of contact with district nurses, dentists and other health professionals. Comments from residents showed they were very satisfied and content with the care provided. It was clear during conversations with staff that they take an interest in the well being of each resident and try to provide them with a good quality of life. Some areas of good practice were seen, for example the way in which staff approached residents who were resistant to attend to their personal care needs and those needing encouragement to eat and drink. Ashville Care Home DS0000049481.V327028.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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s lifestyle in the home matches their expectations and they are helped to exercise choice and control over their lives as much as possible. EVIDENCE: Residents said staff were very good at keeping them entertained, and that they were not made to join in with games and other activities if they didn’t want to. This was also noted on some of the care plans seen. Staff said they made good use of the local facilities and that the home was part of the local community. One carer has been given the responsibility of organising events in the home. In the afternoon a games session was held in the dining room. Residents were given a choice to join in and given time to assemble. Other residents were given other activities to do if they preferred. The inspector sat in the dining room whilst the main meal of the day was being served. Meal times are staggered and there are two sittings. The manager said this was a new idea being tried to give those residents needing assistance better one to one attention whilst preserving their dignity. The separate sitting Ashville Care Home DS0000049481.V327028.R01.S.doc Version 5.2 Page 13 is for residents who might only need prompting to eat and drink and could eat independently. Residents said the meal served was typical of the good standard at every mealtime. The menus for the week are displayed on the notice board in the hallway. The cook said she regularly speaks to the residents to see if they want to make any changes to the menu. There are choices available at all meal times and alternatives are offered if they do not want what is on the menu. Residents’ said they usually ate in the dining room and that they could choose where they wanted to sit any other time. The manager said residents did not have set seating arrangements and residents said they liked this. There used to be two dining rooms, but using one area for two sittings seemed to benefit the needs of the residents. The second dining room was now being used as a quiet lounge. The inspector talked to the manager about the method of assistance given by staff in the dining room during the meal. The manager had already identified this as a shortfall and had altered the roles of carers to make use of their individual strengths. The kitchen was clean, tidy and well organised. Records of cleaning schedules, food delivery, serving temperatures and fridge temperatures are kept. The cook prepares the main meal of the day. A kitchenette, which has a surface for serving, microwave, fridge, dishwasher and sink, has been fitted in the dining room. Staff serve breakfast and teas from here. Hot water is brought up from the main kitchen in flasks for making hot drinks. A hot trolley is brought into the dining room at meal times to allow residents to look at the food on offer to help them make a visual choice. This is of value to residents with dementia, as they cannot always make a choice from a verbal list of options. Some residents shared their views about the home: • They (staff and manager) are very good to me. • I love it here. • Yes, I know the manager. I talk to her and her husband about things. • I’ve enjoyed every minute since coming. • The food is very good • I get what I want to eat, if I don’t like something they know what I like. • My daughter brings me my beer and I get a glass with my meal. • I don’t have to join in if I don’t want to; I go in my room with my things. Some residents who were not able to talk about their experiences showed they recognised the manager and staff in their responses to them and felt safe in their presence. There was an atmosphere of calmness throughout the day. Staff said they are not under pressure to meet tight timescales and routines by a specified time. There was an emphasis on making sure residents were comfortable. Staff did not walk past residents without acknowledging them and if residents were Ashville Care Home DS0000049481.V327028.R01.S.doc Version 5.2 Page 14 looking ‘lost’ or unsure staff picked up on this straight away. Residents were spoken to in a calm and professional manner and given time to make their views known irrespective if they were able to talk or not. The layout of the building allows residents to walk around freely and select different areas to sit in. There were a number of clocks around the home, all showing different times, this was confusing. It is important that visual aids support residents. In the interests of residents with dementia it is of value for signs in the home, which point out key areas. So they are able to identify areas such as toilets and lounges and therefore maintain some of their independence. The manager does not hold residents meetings but is looking at ways introduce these. She is aware of the difficulties of engaging residents who have some memory impairment or dementia in discussion. All accidents and incidents in the home are being recorded. Ashville Care Home DS0000049481.V327028.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The level of staff understanding gives assurance that complaints will be taken seriously and service users will be protected from abuse. EVIDENCE: There has been one complaint since the owners took over in May 2006. This had been dealt with by the home and the complainant had been satisfied with the response. The details and outcome had been recorded. Residents said they knew how to complain and who they could talk to if they felt unhappy. Staff spoken to on the day said they had received training on adult protection and further training is scheduled to take place in March 2007. The home has an adult protection policy. Ashville Care Home DS0000049481.V327028.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, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of decoration and maintenance of the home is satisfactory and good in parts where refurbishment has taken place. Some requirements have been made to make sure the home meets the standards. EVIDENCE: The new owners are in the process of improving the environment and have an action plan to work to. They have already provided new furniture, carpets and redecoration. Ensuite facilities have been fitted to the three double bedrooms and further work is planned to provide extra rooms for hairdressing, treatment and office space. There are bathrooms and toilets on both floors used by residents. Staff areas such as the laundry and kitchen are in the basement. Ashville Care Home DS0000049481.V327028.R01.S.doc Version 5.2 Page 17 Resident’s bedrooms are individually decorated and furnished giving the feeling of individuality and ownership. The nurse call system was tested in two separate parts of the home. Responses by staff were good on each occasion. The member of staff responding to the bell arrived within a minute and cancelled the bell at source. This shows that staff do not leave a bell ringing for long through the day and that they have to visit the room, where the bell is activated and cannot cancel the call at a central panel without checking the reason for the call. No comments received during the visit suggested that there were problems with the call system working effectively during the night. The home employs cleaning staff who work seven days. The home was clean and tidy. However, not all areas smelt fresh. One bathroom, a corridor and bedroom had an unpleasant smell. The manager had already organised to have the corridor and bedroom recarpeted the following day. However the source of the smell in the bathroom was not obvious. The manager agreed to investigate this and resolve it. The kitchen area is well organised. The cook said all the equipment was working. However in view of the number of residents being catered for it is strongly recommended that a bigger hob and oven is provided. Other requirements: • • • • • • • • The devise used to kill insects and flies is in a position, which means dead insects can fall onto food preparation surfaces. This needs to be repositioned. The front of the boiler is not fixed and the pilot light is visible. This should be refitted. The unwanted furniture being stored at the bottom of the fire escape stairs needs to be disposed of properly as it was obstructing the fire exit. All self-closing devises on fire doors need to be checked to make sure they are working properly. A sign needs to be put on the door leading to the cellar to warn of immediate steps. Outside areas need to be kept free of trip hazards and moss and any debris needs to be removed to minimise the risk of people slipping. Fencing around the grounds needs to be reviewed to minimise the risk of residents climbing over it. Some of the drops at the other side of the fence are significant. There are no records to show that the fire alarms are being tested weekly or that staff have been instructed on what to do in case of a fire. Apart from the above, information provided by the owner confirms that equipment and services are being maintained according to health and safety laws. Ashville Care Home DS0000049481.V327028.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are competent to look after the residents. The manager works alongside staff and offers good leadership and guidance. EVIDENCE: The manager was present during the inspection. The information provided before the inspection showed that two members of staff had been recruited since the last inspection and six people had left. This included the manager who had retired. Since then the newly appointed manager has been registered with CSCI after completing the registration process. The recruitment files of the new staff were seen and all the necessary pre employment checks had been made to make sure they were suitable to work with the vulnerable people. The manager has been on a course with the Home Office and knows the rules around employing staff from overseas. Staff are responsible for reading all procedures and staff instructions and they sign to say they have read these. Two staff members are provided at all times during the night and four staff at any other time. The manager and Director of Care work across seven days Ashville Care Home DS0000049481.V327028.R01.S.doc Version 5.2 Page 19 and at different times of the day to make sure they are available to see staff and work in the home alongside staff. There are suitable on call arrangements. Staff training is provided and a forthcoming programme of courses includes topics such as; moving and handling; food hygiene; first aid and adult protection. Staff said they had attended courses in the past, including dementia awareness and medication administration. However, there was little written evidence in the home to support this. Training records prior to the new owners taking over had been removed. Staff meetings are being held. The minutes of the most recent meeting were seen. Ashville Care Home DS0000049481.V327028.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, 32, 35, 36, 37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed and run in the best interests of residents. EVIDENCE: The manager is a very experienced and is well thought of by her staff and the residents living at Ashville. She has nearly completed a management qualification, which is recognised by CSCI. Residents’ looked well cared for and attention had been given to their appearance and grooming. Ashville Care Home DS0000049481.V327028.R01.S.doc Version 5.2 Page 21 The home employs an administrator who deals with resident’s finances; this is overseen by the manager. This practice was inherited from the previous owner and steps are being taken so that the home does not handle money on a resident’s behalf. Any expenditure incurred over and above the agreed fee will be added to the bill and paid directly by the representative. Until this practice is fully adopted any purchases made on residents behalf is receipted and a record of the transaction is kept both on the computer and a cash register. Two residents have legal restrictions on their financial arrangements. All records are kept in a locked filing cabinet in the office when not being used. The owner and manager are in the process of updating the current policies and procedures. These are up to date but need to be revised so that they are specific to Ashville. Ashville Care Home DS0000049481.V327028.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 3 X 3 3 3 N/A 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 3 3 3 3 2 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 3 X X 3 3 3 3 Ashville Care Home DS0000049481.V327028.R01.S.doc Version 5.2 Page 23 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 12, 13, 15(1) & 15(2) Requirement The registered person must make sure the care plan is kept up to date and is accurate. Any identified need and the action taken must be recorded. Care plans must be reviewed monthly and risk assessments must be carried out routinely. The registered person must make sure that all staff who are assisting resident with their meals must be skilled to do so. The registered person must make sure residents with dementia are given every assistance with their daily living routines. Better signage around the home and clocks showing the correct time are examples of where improvement is needed. The registered person must make sure the home does not smell unpleasant. The registered person must make sure action is taken to address the following: • Relocate the devise used to kill insects and flies so it is not above a food DS0000049481.V327028.R01.S.doc Timescale for action 14/04/07 2. OP12 12(1)(b) & 12(4)(a) 23 03/03/07 3. OP12 14/04/07 4. 5. OP26 16(2)(k) 13, 16 & 23 03/03/07 28/03/07 OP19 Ashville Care Home Version 5.2 Page 24 • • • • • • • preparation surface. Fix the front of the boiler so that the pilot light is not visible. Do not obstruct any fire exits. Keep all self-closing devises on fire doors in working order. Put a sign on the door leading to the cellar to warn of immediate steps. Keep outside areas free of trip hazards and moss and any debris to minimise the risk of people slipping. Review the fencing around the grounds to minimise the risk of residents climbing over it. Some of the drops at the other side of the fence are significant. Keep a record of when the fire alarms are being tested and when staff are instructed on what to do in case of a fire. 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 OP19 Good Practice Recommendations It is recommended that a bigger oven and hob are provided in the main kitchen to make it easier to cook for the number of residents in the home. Ashville Care Home DS0000049481.V327028.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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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