Inspection on 15/01/08 for Ashwood

This inspection was carried out on 15th January 2008.

CSCI found this care home to be providing an Adequate 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

Ashwood 21/10/08

Ashwood 19/07/06

Ashwood 23/01/06

Ashwood 02/06/05

Ashwood 28/10/04

Ashwood 02/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Ashwood 1 Liverpool Road Ashton-in-Makerfield Wigan Greater Manchester WN4 9LH Lead Inspector Judith Stanley Unannounced Inspection 15th January 2008 09:40 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 Ashwood DS0000005722.V357433.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. Ashwood DS0000005722.V357433.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashwood Address 1 Liverpool Road Ashton-in-Makerfield Wigan Greater Manchester WN4 9LH 01942 722553 01942 720577 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Serge Pascau Mr Dennis Pugh Mrs Sandra Shepherd Care Home 36 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (36), of places Physical disability (2), Physical disability over 65 years of age (8) Ashwood DS0000005722.V357433.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 36 service users to include: up to 36 service users in the category of OP (Older People) up to 2 service users in the category of PD (Adults with Physical Disabilities) up to 8 service users in the category of PD(E) (Adults with Physical Disabilities over 65 years) up to 1 service user in the category of DE(E) (Adults with Dementia over 65 years) The 2 PD places are only to be used for service users over the age of 60. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 19th July 2006 2. Date of last inspection Brief Description of the Service: Ashwood is a privately owned care home that offers care for 36 older people. It is situated in the centre of Ashton-in- Makerfield close to all local amenities including shops and bus routes. Ashwood offers accommodation to people who require assistance with personal care and support. Ashwood is a purpose built two-storey home that can offer care for 36 residents. Currently all bedrooms have single occupancy. The home is registered for 36 so there is a possibility some of the large rooms could revert back to being used as shared rooms. The manager advised that there are currently no plans to have shared rooms. Only one room offers an en suite facility, however, all rooms have a hand basin and there are toilets and bathrooms on both floors. Level access to the home is provided and a passenger lift ensures access is available to both floors. The premises are well maintained both inside and outside. Car parking is available to the rear of the home. The current scale of fee ranges from £322:65 to £387:00. Additional charges are made for toiletries, magazines, transport, papers and hairdressing. Ashwood DS0000005722.V357433.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 1 star. This means the people who use this service experience adequate quality outcomes. This key inspection included a site visit, which the home did not know was going to happen and took place over a period of 5¼ hours. The homes manager although still on sick leave was at the home and wished to assist with the inspection. Part of the time was spent looking at information the home holds on residents (care plans) and other records the home needs to keep to ensure the home is being properly run. The inspector spoke with the owner, the manager, staff, residents and relatives throughout the course of the day. Prior to the inspection the manager was sent an Annual Quality Assurance Assessment (AQAA) to complete. This is a self-assessment form and informs the inspector of how the home meets the National Minimum Standards (NMS), what the home does well at and where improvements could be made. To find out more about the home from the people who use, work and visit the service comment cards were sent to residents, staff and relatives. We received eight from staff, one member of staff said, “We do our best for all our residents to provide a good home”. Another commented, “ The management are always trying to improve things, it’s a homely friendly environment, we care for our residents well”. Ten residents completed comment cards. One said, “ Staff are willing to listen. I am very satisfied living here; I have no complaints”. Although there were no further comments added to the questionnaires, other residents indicated their satisfaction about living at the home and the services and facilities provided. One resident spoken with told the inspector, “It’s the best thing I’ve done coming to live here, I made new friends, the food is good and staff are lovely, I give this home 110 ”. Seven relatives returned comment cards, all responses were positive. One relative said, “The home communicates well with me. I get on well with the staff”. Another said that, “The home provides an excellent service for vulnerable people”. There have been no complaints made to the manager of the home since the last inspection. A letter of concern had been forwarded to the inspector prior to the inspection. This was anonymous and the concerns were unfounded. Ashwood DS0000005722.V357433.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The outside of the home had been painted and the garden area has been made safe and secure for residents to sit outside. The overhanging trees had been cut down making the outside area lighter. An extra member of staff is on duty on the evening shift to help cover that busy period of the day. A new shower room upstairs was being worked on. There was evidence of redecoration, which is ongoing. New flooring had been laid in the downstairs lounge and outside the kitchen area. Paper towel and hand wash dispensers had been fitted in all resident’s rooms. The home has invested in a computer for residents to use; this is situated in the downstairs lounge. Ashwood DS0000005722.V357433.R01.S.doc Version 5.2 Page 7 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. Ashwood DS0000005722.V357433.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 Ashwood DS0000005722.V357433.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): 1,2,3 and 4 were assessed. Standard 6 does not apply, as Ashwood does not provide an intermediate care service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides residents and their supporters with up to date information about the home that helps them in making a decision about moving in and the services provided. A full assessment is carried out prior to admission to ensure the home can meet the needs of the individual. EVIDENCE: The home has a statement of purpose and a service users guide. This is available to prospective residents and to residents all ready living at the home. The information informs people of the services and facilities available within the home, about the staff that work there and the homes complaints procedure. The last CSCI report is also available in the home for anyone to read. Ashwood DS0000005722.V357433.R01.S.doc Version 5.2 Page 10 The manager confirmed that all residents have a contract/ statement of terms and conditions regardless of how their care is purchased. We selected two residents care plans for inspection and both contained a resident’s contracts. An assessment is carried out prior to admission. This is carried out at the home or in a convenient place for the prospective resident. The purpose of the assessment is to ensure that the home and staff can meet the needs of the individual. When completing the assessment the manager looks at a persons orientation, communication, sleep pattern, nutrition, social relationships, mobility, what the person can do for themselves, for example dressing themselves, feeding and continence etc. Three residents have a diagnosis of a dementia related illness; some of the other residents are a little confused at times. To ensure that staff have the right skills to provide good specialised care to these residents staff including kitchen staff have undertaken dementia care training. Ashwood DS0000005722.V357433.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 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans are clear and concise and provide staff with the information they need to meet the needs of the residents. Personal support is offered in such a way as to promote and protect resident’s privacy and dignity. EVIDENCE: We continued to use the two care plans chosen to check the pre admission assessment for further inspection. The information contained in the care plans gave staff detailed information about the care each resident required. A social profile was included which informs staff of the life experiences of the resident’s, this helps staff to get to know them better and generate topics of conversation. The profile includes family background, work life experiences, etc. Ashwood DS0000005722.V357433.R01.S.doc Version 5.2 Page 12 Other information in the care plan includes risk assessments, for example moving and handling and mobility, to ensure the residents safety is maintained. There was evidence to demonstrate in the care plans that outside agencies, such as doctors, district nurses and the chiropodist are contacted and visit the home as required. The care plans had been reviewed monthly as required and where possible the care plans were signed by the residents. Observation throughout the inspection showed that the personal care needs of the residents were being met. Attention was given to residents personal grooming; residents were seen to be clean and nicely dressed in coordinated clothing. Ladies had had their hair done and gentlemen were clean-shaven. Throughout the inspection it observed that relationships between staff and residents were very good. A friendly, respectful rapport was noted. Staff were tentative to the resident needs and requests. Staff were observed maintaining residents privacy by knocking on doors before entering and in assisting residents to the bathroom. We inspected the medication of the residents whose files were inspected. The deputy manager assisted with the check. It was found that in both cases there were errors in the medication. In one case the medication had been signed for but had not been given to the resident. The second case was that the resident had two additional tablets that she should not have had. The errors could not be accounted for. The errors had occurred with the additional medicines that were boxed. On checking the blister packs for both residents these were found to be in order. The controlled drugs were checked and no errors in administering or recording were noted. These errors were discussed with the manager who confirmed a full audit of all resident’s medication would be carried out. Ashwood DS0000005722.V357433.R01.S.doc Version 5.2 Page 13 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. Residents are provided with well-cooked food and are offered good variety and choices. EVIDENCE: A range of activities is available to residents who wish to partake. The activities are displayed so residents and relatives are aware of what is happening in the home. The range of activities includes games, bingo, dominoes, gentle exercise, range of DVDs, and manicures, trips out and visits from entertainers. Residents now have access to a computer, in the downstairs lounge. One resident with the assistance of staff had purchased some goods on line. One relative spoken with told the inspector about events over the Christmas period and said that the Christmas party and buffet provided by the home for residents and relatives was ‘great’. Staff are now recording what activities residents are taking part in, this was evidenced in the care plans. Ashwood DS0000005722.V357433.R01.S.doc Version 5.2 Page 14 Visitors are welcome to visit the home at any time; there are no restrictions as to when people can visit. Residents can meet with their visitors in one of the lounges or in the privacy of their own rooms. Two regular visitors to the home were spoken with and indicated their satisfaction of the care their relative receives. Links with the local community are actively encouraged. One resident was seen going out unaccompanied, the resident goes for a walk, weather permitting and calls at the local pub on his way back; he also attends the local church. There are regular visits to the home by the local clergy who offer communion to residents who wish to take communion but cannot get to church. Residents confirmed they got up when they wanted and went to bed when they were ready. The manager said when she arrived at the home at 08:30 am on the day of the inspection only two residents had wanted to get up. The inspector spoke at length with the cook. The cook confirmed that there was always plenty of food in the home and that they got regular deliveries of fresh vegetables, fruit and meat. The cook added, “What the residents want to eat the residents get”. A good selection of hot and cold breakfast dishes is offered and a choice of drinks provided. Lunch is the main meal of the day and residents had the choice of sausages, creamed potatoes, vegetables and gravy, followed by sponge pudding and custard or fresh fruit. The alternative to the main dish was scrambled eggs on wholemeal toast. One resident who was attending a hospital appointment at lunchtime had had sandwiches made for her earlier then she would not be hungry. A lighter afternoon tea is served and again residents are offered a good choice of meals. Suppers are available before residents retire; a range of snacks and choice of drinks is offered. Any special diets required could be catered for, such as soft or pureed food or a diabetic diet. Residents spoken with expressed their satisfaction at the quality and quantity of the meals served. Ashwood DS0000005722.V357433.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 and 18 were assessed. 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, can have the confidence that residents will be protected from abuse and have their rights, including the right to complain, protected by effective staff training and procedures. EVIDENCE: A complaints procedure exists and records of any complaints made would be kept and properly recorded. The complaints procedure is in the foyer and a copy is given to residents on admission, copies of the complaints procedure was seen in the two residents care plans inspected. Information on the AQAA shows that there had been no complaints made to the manager of the home. The CSCI had received one anonymous letter regarding some areas of concern. This was discussed with the owner and manager and there was no evidence found to substantiate the alleged concerns. There has been one incident regarding the safety and welfare of three residents, this was related to one member of staff. The home reacted efficiently and appropriate action was taken. The member of staff is no longer working at the home and is being referred to the Protection of Vulnerable Adults List. Ashwood DS0000005722.V357433.R01.S.doc Version 5.2 Page 16 Staff had received training in the Protection of Vulnerable Adults, which had benefited them and gave them the confidence to know what action they needed to take with the above incident. Ashwood DS0000005722.V357433.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,24, and 26 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Ashwood provides a safe, comfortable, and homely environment for residents living at the home. EVIDENCE: From a tour of the premises it was evident that the home has an on going programme of maintenance. Some of the bedrooms had been decorated and the lounge/dining area downstairs had had a new floor laid. The flooring had also been replaced near the kitchen area. A new shower room on the first floor is under construction. It was discussed with the owner and the manager that the corridor carpets on both floors are in need of replacing and these were seen to be heavily stained in parts. Ashwood DS0000005722.V357433.R01.S.doc Version 5.2 Page 18 The carpet in one resident’s room on the ground floor needs to be replaced as this was stained and looked unsightly. The chairs, mainly in the upstairs lounge were in need of cleaning; the chair arms were stained and marked. The outside of the home has been repainted and the garden landscaped and made safe and secure. The ramps leading down into the garden area benefit more able residents and those using wheelchairs to access the garden more easily. The over hanging trees had been cut back to provide more light to the garden area. It was discussed with the owner and the manager about the smoking arrangements for residents living at the home. The downstairs lounge has been designated as the residents smoking area and residents have signed to say they are happy to be in this area. However under the Smokefree Law that came into force on 1st July 2007 this area does not comply with the regulations and alternative arrangements should be made to accommodate the residents that smoke in the home or introduce a no smoking policy for the home. A number of bedrooms were looked at and were found to be warm, clean and comfortable. Residents had personalised their rooms with personal belongings and mementoes brought with them from home. Systems were in place to control the risk of cross infection. Staff were seen wearing different protective clothing when carrying out different tasks. The laundry area is sited away from food preparation and food storage areas and does intrude on the residents. In the main the home is clean and free from offensive odours. Ashwood DS0000005722.V357433.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be sure that their needs can be met by good staffing levels and with a competent, committed, experienced and well trained staff team. EVIDENCE: The staff rotas showed that there are sufficient numbers of staff on duty each day and through the night. The manager has put an extra member of staff on duty during the evening to help cover the busy period. Domestic staff are employed in sufficient numbers to cater for the needs of the residents and to support the care staff. Several of the staff had worked at the home for a number of years this provides continuity for residents by people they know and trust. From discussions with the manager and her staff it was evident they know the residents well and they demonstrated a strong commitment to providing a good standard of care. Staff were clear about the work they were employed to do and that they were happy to help each other out. Staff morale appeared to very good. Ashwood DS0000005722.V357433.R01.S.doc Version 5.2 Page 20 Staff training is ongoing and the home has surpassed the 50 mark required of staff qualified to NVQ level 2 or above. Mandatory training for all staff was up to date and valid certificates were available for inspection. The home ensures that there is a qualified first aider on every shift. A full copy of each members of staff’s employment file is kept at the home in a secure location. The file for the last mostly recently recruited employee was looked at and was complete and up to date. A second file of a longer standing member of staff was also examined and found to be up to date. Files contained an application form, two written references, job descriptions, induction and other forms of identification. Confirmation of Criminal Records Bureau checks for all staff was available in a separate file. Ashwood DS0000005722.V357433.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, and 38 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Ashwood is well run by a well-qualified, suitably experienced and competent manager. Residents can be sure their best interests will be the central focus, with a positive and inclusive approach to making the service better. EVIDENCE: The home’s manager has a significant numbers of years experience in working with elderly people and is qualified to NVQ level 4 in care and also had the Registered Managers Award. Ashwood DS0000005722.V357433.R01.S.doc Version 5.2 Page 22 The home’s manager is committed to her own training and that of her staff team and sees this as an essential element to delivering good quality care for residents. During the inspection the manager who was officially still on sick leave assisted with the inspection, which was her choice. The manager accompanied the inspector around the home and the resident’s responses in seeing her back in the home was a credit to how she manages the homes and the relationship she has with the residents. Comments included, “Its lovely to have you back”, “ We’ve missed you”. One resident said to the inspector when referring to the manager, “She a great girl”. There are clear lines of accountability and seniors are being encouraged to expand their skills. One of the seniors had recently been promoted so the home now has two deputy managers. The newly appointed deputy manager confirmed he was pleased with his promotion and was settling into the role. The way that the home is managed, and run is open and transparent. The manager operates an ‘open door’ policy so that she may be approached at any time by staff, residents or their families. The residents and visitors on the day of the inspection were seen to approach her mainly to welcome her back. The office is organised so that staff have access to the paperwork and contact information they need during a shift. Systems were in place for continuous self-monitoring in the home, which includes satisfaction questionnaires, staff meetings, residents meetings, some weekly or monthly audits take place and there two main audits within the year. The owner of the home visits on a regular basis and completes a monthly written report on his findings. An external company RDB has also inspected the home. RDB inspect the home and award a star rating leading to a financial enhancement. Ashwood has been awarded five stars. RDB has no connection to CSCI. The home has obtained the Investors in People Award in July 2007 for another three years. Some of the residents living at Ashwood have handed over the responsibility for the financial affairs to their families but keep a small amount of money with the manager for safekeeping. A sample of residents’ monies was checked and found to be in order and matching the written record of transactions. The manager described the process of staff supervision, which ensures accountability and support for staff at all levels. There was evidence of supervision notes in the long -standing member of staff file. Ashwood DS0000005722.V357433.R01.S.doc Version 5.2 Page 23 The second file did not have supervision notes and the member of staff had only recently started working at the home. However a full induction had been carried out for this member of staff. Equipment and systems used in the home are serviced and maintained, and records kept. The information provided on the AQAA form states that following servicing and maintenance checks have taken place: Electrical circuits: August 2006 (5 year certificate) Portable appliances: January 2007 Gas appliances: November 2007 Lift: September 2007 Hoists: September 2007 Water temperatures are tested weekly. The inspector randomly checked some maintenance certificates and these were seen to current and valid. Accidents, injuries and incidents were documented and the CSCI are kept informed at all times. Ashwood DS0000005722.V357433.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 3 3 3 3 x N/A 3 X x x x 3 x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 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 4 x 3 x 3 3 x 3 Ashwood DS0000005722.V357433.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 OP9 Regulation 13 Requirement There was an error in two resident’s medication. All medication must be accounted for and appropriately recorded. Timescale for action 16/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP19 OP19 Good Practice Recommendations In accordance with the Smokefree Law that came into force on 1 July 2007, the home must make alternative arrangements for residents who wish to smoke. The carpets in one resident’s room on the ground floor and the carpets on both floors need replacing as these were stained passed cleaning. The owner confirmed he was looking into replacing them soon. Ashwood DS0000005722.V357433.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ashwood DS0000005722.V357433.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!