Inspection on 20/07/07 for Ash Court Care Centre

This inspection was carried out on 20th July 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

Ash Court Care Centre 09/11/06

Ash Court Care Centre 22/02/06

Ash Court Care Centre 11/01/05

Ash Court Care Centre 02/08/04

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

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

CARE HOMES FOR OLDER PEOPLE Ash Court Nursing Home Ash Court Ascham Street London NW5 2PD Lead Inspector Pippa Canter Unannounced Inspection 20th July 2007 10:00 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 Ash Court Nursing Home DS0000010320.V333595.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. Ash Court Nursing Home DS0000010320.V333595.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ash Court Nursing Home Address Ash Court Ascham Street London NW5 2PD 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) 020 7419 7474 020 7419 7676 nancy.rasool@foresthc.com Ash Court Community Limited Nancy Abdul-Rasool Care Home 62 Category(ies) of Old age, not falling within any other category registration, with number (0), Physical disability (0) of places Ash Court Nursing Home DS0000010320.V333595.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following category of service only: Care home with nursing - Code N 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 2. Physical Disability - Code PD The maximum number of service users who can be accommodated is: 62 9th November 2006 Date of last inspection Brief Description of the Service: Ash Court is a purpose built care home with nursing. It is privately owned and managed. It can accommodate 62 people from the age of 60 years in 58 single and 2 double rooms. Sixteen of those places can be used for service users requiring personal care only. The level of fees has not been recorded in this draft report but will be included in the final report. The home is sited in a courtyard in a residential area. Access to the home is through a gated driveway. There is sufficient care parking space for 10 cars at the front of the property. The nearest underground station is Kentish Town and the home is on the C11, 134 and 204 bus routes. Entry into the complex is only through the security gate. The front entrance is covered by a large conservatory, which is used by service users. Although a garden is not available service users have access to limited but well-presented outside space. The home is spread over three levels. Each floor is self-contained, with bedrooms, assisted bathrooms and seating-cum-dining areas. Each floor is staffed independently. There is a main kitchen and laundry room, which serves the whole home. All the bedrooms have an ensuite toilet and hand basin. Each room has a variable height profile bed. There are cantilever tables and footstools available. Room sizes, corridor widths and doorframes are large Ash Court Nursing Home DS0000010320.V333595.R01.S.doc Version 5.2 Page 5 enough to allow access to wheelchair users or zimmer frames. A nurse call system is installed throughout the building. There is a shaft lift that gives access to the upper floors. Ash Court Nursing Home DS0000010320.V333595.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over the course of one day, which lasted from mid-morning until early evening, about seven and a half hours in total. The manager was available and assisted the inspector along with additional input from staff on duty, visitors and people living in the care home. Records such as care plans, assessments and menus were examined. The care plans were also cross-referenced with other records, such as complaints and accident and incident reports. A partial tour of the building was made. Four service users were asked for their views of the running of the service and talked about their experiences of being in the home; though some were unable to give them due to their level of disability. Staff were observed fulfilling their roles and responsibilities and were involved in general discussion with the inspector. Service users and staff were spoken to during both, and lunch was observed being served during one of the unaccompanied tours. Some staff were asked about aspects of care, and of their experience of working at the home. Staff recruitment, supervision, and training records were examined. Prior to the inspection we looked at all the information we had about the home, including notifications of accidents or serious incidents and previous inspection reports. The manager had returned an Annual Quality Assurance Assessment, which confirmed some useful information about the service. Comments cards for service users and relatives were left for collection in the home. Other surveys were sent out to Care Managers and a GP surgery. Any feedback received is reflected in this summary as well as the main body of the report. We reviewed all the evidence and it has allowed us to form a judgement about the outcomes for people living in the home. At the end of the inspection, general feedback was given to the manager and an email has also been sent A feedback form will be sent along with the draft report so the manager can let us know how she felt about the inspection process. What the service does well: When people are referred to the care home, they receive support and have been through a full assessment. A comment receive about the admission process was, “Our introduction to the home was excellent. My father has settled in well. I have been very impressed with the kindness shown to my Ash Court Nursing Home DS0000010320.V333595.R01.S.doc Version 5.2 Page 7 mother for whom this has been a difficult time. Credit should be extended to the Manager and staff.” The service has an established and well-presented care planning system, which supports staff to meet the needs of people with complex health and personal care needs. The home has fostered good relations with medical and social care professionals. Comments received were, “My father has numerous health issues both physical and mental health. Staff at Ash Court address all issues at a highly professional level.”, and “The staff I have encountered seem very caring and well motivated. My father seems very clean-shaven and well fed. Any medical issues seem to have been spotted quickly and acted upon.” The home has been purpose built. It is secure and there is full disabled access. All bedrooms have ensuite facilities. The home is generally well decorated, furnished and maintained. The successful bid for extra funding, which enhance the facilities already available. The manager has chosen to use the funding for specialist equipment that will meet the changing needs of the people who live in the home. The home is effectively managed. The communication has been described as “excellent” and positive remarks were made about the calibre of the manager and the staff. These were ““A seemingly well motivated staff”, “Ash Court seems to have created a very effective team.”, “My father is getting excellent clinical and personal care at Ash Court.” “I think Ash Court is excellent. The manager, Nancy Rasool, has all the qualities required; and the staff are great. The home has lived up to my expectations when it was chosen.” “Communication is excellent.” “I’ve never found anything lacking.” “I honestly cannot think of anything that could improve Ash Court.” What has improved since the last inspection? An inspection by a Pharmacist from the Commission for Social Care Inspection identified areas where improvements in the management of medication must be made. This site visit has shown that the staff have been responsive and progress has been made in all areas. As identified in the section above there is a consistent approach to the preadmission assessment. Ash Court Nursing Home DS0000010320.V333595.R01.S.doc Version 5.2 Page 8 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. Ash Court Nursing Home DS0000010320.V333595.R01.S.doc Version 5.2 Page 9 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 Ash Court Nursing Home DS0000010320.V333595.R01.S.doc Version 5.2 Page 10 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 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service can be assured that their needs will be fully assessed and their needs and aspirations will be recognised and met. EVIDENCE: A total of four care records were examined. The people had been admitted since the last inspection. A requirement had been set at the last inspection because the quality of the assessments had been inconsistent and did not reflect the cultural or religious needs of some of the people who had been referred. People were asked about their experiences during the admission process. All four care records examined contained pre-admission assessments. Those referred by Social Service Departments, had copies of assessments and care plans under the care management process but the home had also completed a Ash Court Nursing Home DS0000010320.V333595.R01.S.doc Version 5.2 Page 11 pre-admission documentation that was detailed enough to ensure all needs would be addressed on entering the home. The manager confirmed that the admission process had been improved by listening to feedback from people who had visited the service. The care home recognises and does not underestimate the anxiety that is experienced because of the major life change. People using the service reported that the admission process had been supportive. A comment was “Our introduction to the home was excellent. My father has settled in well. I have been very impressed with the kindness shown to my mother for whom this has been a difficult time. Credit should be extended to the Manager and staff.” Ash Court Nursing Home DS0000010320.V333595.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is continuous assessment, care planning and review which makes sure that the personal and healthcare needs of the people living in the home are met EVIDENCE: A sample of four care plans were examined, which included looking at the daily recording for the previous three weeks. The care records were a sample from each of the upper floors and two from the ground floor. They included needs specific to racial origin, complex medical conditions, recent admissions and dementia. In each case we met with the person concerned but could not discuss their care with them in all cases. The relatives, health care professionals and care managers involved with each person was also asked for their feedback. A comparison was made between the care recorded in the records and the care being received by each resident. A sample audit was taken on each floor of the medication administration systems. Ash Court Nursing Home DS0000010320.V333595.R01.S.doc Version 5.2 Page 13 All care plans were found to be up-to-date and reflected the needs and wishes of each individual service user. The care records were comprehensive and important health and personal care needs were clearly identified. Where additional assessments were indicated, such as manual handling, risk of pressures sores and nutritional risks, these had been carried out and were reflected in the care plans. Samples of falls risk assessments and incontinence were also available. From observation and discussion with people using the service is was clear that service delivery matched the care plans. A comment received was “My father has numerous health issues both physical and mental health. Staff at Ash Court address all issues at a highly professional level.” As from previous inspections the care records clearly show referrals to and the involvement of other health care professionals. The records show that the registered nurses have identified changes in condition or behaviour and have referred to the General Practitioner (GP). A relative commented, “The staff I have encountered seem very caring and well motivated. My father seems very clean-shaven and well fed. Any medical issues seem to have been spotted quickly and acted upon.” All service users are registered with a local GP. Entries in care records show clear evidence of collaborative care with interventions from Occupational Therapist, Physiotherapist, Chiropodist, Dietician and a Tissue Viability Nurse. Dental and Optical needs are also addressed. As the result of an allegation that, staff were clandestinely crushing residents’ tablets, a full inspection was requested by a Pharmacist from the Commission for Social Care Inspection. Although the outcome of the inspection was that the allegation was false as consent had been obtained for people with swallowing difficulties although it was advised that liquid alternatives are available. The pharmacy inspection did show the management of medication within the home needed to improve. As part of this site visit. A sample audit only was taken on all three floors. It was highlighted that there had been a marked improvement in accurate recording of receipts, administration and disposal of medication. Observation on the day of the site visit, discussion with staff, feedback from people using the service and the examination of the care records confirmed that staff respect the privacy and dignity of the people they look after. A comment from a relative was “The care and support given to my father, is more than I dared to expect or hope for.” Ash Court Nursing Home DS0000010320.V333595.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, & 15 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Ash Court supports people to live the life they choose but further development is required for people with more complex needs. EVIDENCE: The four care plans seen were comprehensive and included wishes and preferences. The home has started to write up life history books. A look at some of these social histories showed that the information is sparse still and staff need to look at more imaginative ways of gaining this kind of useful background knowledge. This was raised in the previous report as it was considered that such information can be fed into the activities programme as well as enable key workers to provide individual stimulation and occupation. A comment to support this was from a relative “Perhaps they could arrange or provide activities for people like my **** who chooses not to come out of their bedroom.” Despite the paucity of detail, service users were having their social, emotional and religious needs met. Comment received were: “Staff are aware that my ***** enjoys to listen to music in room. When he is stable, staff, settle him in his room with his music – but closely monitoring him Ash Court Nursing Home DS0000010320.V333595.R01.S.doc Version 5.2 Page 15 because of unpredictable falls. My father enjoys to go downstairs to meet other residents – this is actively encouraged.” “The special activities from time to time undoubtedly help to introduce new experiences into the lives of its’ residents – they managed to get my father involved.” “My **** is deeply religious and they are reminded when the Eucharistic Minister visits.” “There are activities, but my *** chooses not to partake in them.” The care home makes visitors and relatives feel welcome as well as maintains a good level of communication with families. Comments received were: “We have visited at almost any time of day and have always felt welcome.” “I am informed immediately if my father’s health deteriorates or any other concerns. Communication is excellent.” “Message are always passed onto my father and staff remind him when family members plan to visit. When I ‘phone my father, staff ask if he want to speak to me.” The menu is on a rolling programme. People living in the home are asked to make a choice of meals for the next day. A comment received was “My **** is a very fussy eater. He is asked what he wants, but does not always want it when he gets it.” The menus are on display and were noted to be varied and offer a range of choices. The teatime menus looks restrictive with soup and sandwiches but discussion with people using the service identified that alternatives to the main menu are always available. The menu reflected peoples’ choices as meat eaters, vegetarians and varying cultural tastes. The food served at the lunchtime meal looked appetising and peoples’ preferences were being served. However it was observed that staff did not always appreciate some of the cultural aspects of popular food. The main meal was fish and chips however a staff member was observed sprinkling vinegar on mashed potatoes and applying tartar sauce liberally to the fish portion instead of the plate. Staff need to be made aware of cultural issues on induction. Ash Court Nursing Home DS0000010320.V333595.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 & 18 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home are fully protected by the approach to complaints, incidents and allegations. EVIDENCE: Complaints, incidents and accidents are being recorded. These records were cross-referenced with the care records of the people being case tracked. The accident reports were compared with the Regulation 37 notifications sent by the service since the last inspection. The home has a comprehensive complaint’s policy and procedure. The procedure is available in the service user guide, which is available in each bedroom as well as being on display in the home; at the front desk and on each floor. Comments received were: “All information about making complaints was given on admission.” “Any health concerns are addressed immediately” “No concerns regarding care” “Any remark is always acted upon. There is never any problem discussing care.” The service has a robust policy and procedure on adult protection, which is linked to local authority guidance. Staff have received training on adult protection and showed that they understood their role and responsibilities in this area for the safety and protection of the service users. The provider ensures that there is a policy and procedure regarding service users’ money Ash Court Nursing Home DS0000010320.V333595.R01.S.doc Version 5.2 Page 17 and financial affairs. There is a system in place for the safe keeping of service users personal monies, which is managed by the administrator. Ash Court Nursing Home DS0000010320.V333595.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 & 26 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who reside in the home live in a comfortable, homely and clean surroundings. They will benefit further from the improvements planned with extra funding. EVIDENCE: There is a secure and gated entrance and the home is accessible to people with physical disabilities. The environment of this home has always been judged as being good at previous inspections. Overall the home was well decorated, furnished and maintained. All the bedrooms are single occupancy with ensuite facilities, which ensures the privacy of people occupying them. Each floor has a communal lounge-cum dining area but people have the choice to remain in their rooms. Bedrooms afford ample room and service users have the opportunity to personalise their rooms. The home provides a safe environment. A nurse call Ash Court Nursing Home DS0000010320.V333595.R01.S.doc Version 5.2 Page 19 system is installed throughout the home and there is a fully integrated fire alarm system; this includes a sprinkler system and smoke detectors in each bedroom. Both systems are maintained by regular servicing. The radiators are low surface and can be controlled individually. Where oxygen is in use appropriate safety signage is displayed. Overall the home was found to be clean and tidy. The home has an infection control policy. Clinical waste is stored in suitable containers and collected on a regular basis through contractual arrangements by a reputable collection agency. Bottles of hand cleanser are available, together with protective clothing such as disposable gloves and aprons. The manager confirmed that the home had made a successful bid for extra funding to improve the facilities in the home including specialist chairs and baths. A comment from a relative was “On a more prosaic point, the room could be cleaned a little more frequently. The waste bins in the room sometimes seem to be missed.” This was the only remark made about the environment that was negative but one that the manager should look into. Ash Court Nursing Home DS0000010320.V333595.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 & 30 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This is a company that has always put a great emphasis on training staff to meet the needs of the people accommodated at the home. EVIDENCE: “A seemingly well motivated staff – individuals will undoubtedly have more challenging days but given the demands made upon them and remuneration levels, Ash Court seems to have created a very effective team.” “The prognosis is poor for my father, but I feel relieved that he is getting excellent clinical and personal care at Ash Court.” The comments above were received from relatives via postal surveys, which were returned as part of the inspection process. People living in the home also made positive comments about the staff described them as “caring”, “reliable” and “good at what they do”. We observed staff working with people, and having warm and friendly relationships with those in their care. Training records showed that a training programme is in place. The home provides a placement for nurses on conversion courses and student nurses, which has a positive impact on the professional development and skill mix of the team. Ash Court Nursing Home DS0000010320.V333595.R01.S.doc Version 5.2 Page 21 Recruitment records were looked at. These were the key workers and named nurses of the people who had been case tracked. All required documents were in place. Ash Court Nursing Home DS0000010320.V333595.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, 37 & 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 being managed in the best interests of the people who live there. EVIDENCE: The current manager has successfully completed the registration process. The manager has worked in the home before and has completed an Annual Quality Assurance Assessment (AQAA) prior to this inspection. The information within the AQAA and further discussions with the manager during the site visit demonstrated a good level of awareness of the strengths of the service and the areas where improvements are necessary. Comments received about the management of the home were: “I think Ash Court is excellent. The manager, Nancy Rasool, has all the qualities required; and the staff are great. The home has lived up to my expectations when it was chosen.” Ash Court Nursing Home DS0000010320.V333595.R01.S.doc Version 5.2 Page 23 “Communication is excellent.” “I’ve never found anything lacking.” “I honestly cannot think of anything that could improve Ash Court.” The judgements in preceding sections of this report have contributed to the judgement in this outcome area. The care home has a welcoming environment and promotes an open and transparent style of management. The company invests in the continuing developing of the staff team. People using the service are protected by the polices and procedures and the r feedback feeds into any improvements to the service. However it became apparent that the monthly reports, which should be in the home following visits from the provider are not available. We looked at the records of people’s personal finances that are handled by the home. The system is managed by the administrator. It is an effective system that safeguards people and it provides a clear audit trail. A sample of health and safety records were looked at. These confirmed that the home is being managed responsibly with essential checks being made. The provider monitors health and safety in the home. There are robust procedures in place to monitor compliance. However during the site visit, the inspector observed staff manoeuvring a wheelchair under a table by lifting it. Staff have attended manual handling training and produce assessments for moving people safely. Each situation must be assessed and it was clear that the dining room table was not appropriately placed. Equipment is serviced regularly and where required repaired or replaced. Ash Court Nursing Home DS0000010320.V333595.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 2 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 2 3 Ash Court Nursing Home DS0000010320.V333595.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 15 Requirement The service has introduced social histories for new admissions but these need to have more detail in order to ensure they are used effectively. As part of the induction and ongoing development, staff must know the customs and cultural influences when serving meals to residents. The monthly reports must be available in the home for inspection. In order to protect themselves and the people they look after, staff must follow manual handling guidance. Timescale for action 31/12/07 2 OP15 16(2)(i) 31/12/07 3 4 OP37 OP38 26 13(4) 30/09/07 30/09/07 Ash Court Nursing Home DS0000010320.V333595.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ash Court Nursing Home DS0000010320.V333595.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Camden Local Office Centro 4 20-23 Mandela Street London NW1 0DU 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 Ash Court Nursing Home DS0000010320.V333595.R01.S.doc Version 5.2 Page 28 - 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!