Inspection on 06/12/06 for St George`s Care Centre

This inspection was carried out on 6th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

St George`s Care Centre 18/03/09

St George`s Care Centre 07/11/05

St George`s Care Centre 04/07/05

St George`s Care Centre 23/09/04

St George`s Care Centre 22/04/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Stoneygate Ashlands Ratcliffe Road Leicester Leicestershire LE2 3TE Lead Inspector Lee West Unannounced Inspection 6th December 2006 13:00 X10029.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 Stoneygate Ashlands DS0000006446.V320482.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 and Care Homes for Adults 18 – 65*. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Stoneygate Ashlands DS0000006446.V320482.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stoneygate Ashlands Address Ratcliffe Road Leicester Leicestershire LE2 3TE 0116 244 8624 0116 270 2318 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) info@prime-life.co.ukwww.prime-life.co.uk Prime Life Limited Mrs Diane Smith Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40), Physical disability (40), Physical disability of places over 65 years of age (40) Stoneygate Ashlands DS0000006446.V320482.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. To accommodate at Stoneygate Ashlands the person under 50 years of age named in variation application number V27722 dated 09.12.05 To accommodate the person under 50 years of age named in variation application number V30203 dated 20.02.06 To accommodate at Stoneygate Ashlands the person with dementia as identified in variation application number V32785 dated 13.06.06 No one falling within category OP to be admitted into Stoneygate Ashlands when there are 40 persons of category OP already accommodated in the home No one falling within category PD to be admitted into Stoneygate Ashlands when there are 40 persons of category PD already accommodated in the home. The minimum age for admission to Stoneygate Ashlands under category PD is 50 years of age No one falling within category PD(E) to be admitted into Stoneygate Ashlands when there are 40 persons of category PD(E) already accommodated in the home. The maximum number of persons to be accommodated at Stoneygate Ashlands is 40 7th November 2005 6. 7. Date of last inspection Brief Description of the Service: Stoneygate Ashlands is a home for up to forty older people, some of whom have physical disabilities. The home is a pleasantly furnished and decorated two-storey building and is situated in a quiet residential area of Stoneygate, Leicester. It is set in extensive grounds, surrounded by lawns and mature trees. Fees range from £269 to £379 for social service funded service users and £405 to £450 for privately funded service users, at present, dependent on the complexity of the care needs of the service users. This service is at present building a new, purpose built, home in the grounds of the present home, which is due to be completed during the summer of 2007. Stoneygate Ashlands DS0000006446.V320482.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection, on 6th December 2006, with a visit lasting 6 and a half hours. The method used was Case Tracking. This is when a number of service users were spoken with about their experiences and expectations of living at the home, their Care plans and other records are analysed, and a tour of the premises undertaken. Staff and visitors views are also sought, to ensure that those living at the home have their needs met and their health and welfare maintained appropriately. The registered manager, Diane Smith was available and assisted with information to formulate the judgements within this report. At this inspection, the progress of the new building was seen and service users were asked about any disruptions to their daily lives during the construction of this new home. The service users spoken with were all positive about the construction site. With the many monitoring the progress. During the construction the maintenance, décor and furnishing of the current establishment were still being kept in good order. What the service does well: What has improved since the last inspection? There has been some improvement within the care plans, which were seen to be objective and to identify the needs of the service users. The food provided at Stoneygate Ashlands “is now much better, with some choices,” say service users. Stoneygate Ashlands DS0000006446.V320482.R01.S.doc Version 5.2 Page 6 Since the last inspection, Prime Time Ltd have developed a good quality rating tool, using the 5 star system to assess their homes. The assessments, carried out by the head office, look into individual care packages, keyworker systems, pre-admission information, flexibility of daily living, social programmes and general atmosphere. They also include service user comments. 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. Stoneygate Ashlands DS0000006446.V320482.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Stoneygate Ashlands DS0000006446.V320482.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Pre-admission assessment is thorough. Service users assessed and referred solely for intermediate care are provided with sufficient support to maximise their independence and return home EVIDENCE: The service users’ files and care plans contained extensive assessment documents, which identified the social and medical history of service users, as Stoneygate Ashlands DS0000006446.V320482.R01.S.doc Version 5.2 Page 9 well as identifying the immediate care needs. Visits by potential service users and their families are supported by the staff at the home. A service user said “my family arranged this place for me, they came and visited and got all the information and it suits what I want.” Stoneygate Ashlands DS0000006446.V320482.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans are in place but do not always include the actions required to meet the personal care needs. In general, the care needs of service users are met, but do not always identify changes necessary on review. Medication policies and procedures are appropriate to protect service users. Stoneygate Ashlands DS0000006446.V320482.R01.S.doc Version 5.2 Page 11 Service users are treated with dignity and their privacy is respected. EVIDENCE: Assessments within the care plans identify care needs of the service users. The actions required to address these needs were not clearly set out in the plans and one service user said “I don’t know what a care plan is.” Another said “I have not been asked about what I can or can’t do for myself.” Reviews are carried out, however, although these reviews are recorded, the care plans do not contain any changes which the reviews identified. For example, one service user had had a fall which was identified, but the risk assessment had not been amended and the plan had not been updated to include the fall, the effect of the fall and the action to take to reduce risk of future falls. None of the service users case tracked wished to deal with their own medication. The home’s procedures were inspected and observed and all records were accurate. The Medicines Administration Records were completed and up to date, and the medication stored, was stored in a locked cabinet and all in date and labelled clearly. Service users said they felt they had no control over this aspect of their care. This issue would be resolved if the care plans contained the personal preferences of the service users. Service users spoken with all said that the staff treated them with respect and they “always knock on my door, which I can lock if I want to.” The rapport between service users and staff observed during the inspection, was seen and heard to be supportive, positive and respectful. Stoneygate Ashlands DS0000006446.V320482.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the 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 adequate. This judgement has been made using available evidence including a visit to this service. Generally, the home meets the lifestyle experiences of service users, but some personal preferences are missed, which reduces the choice and control service users have over their daily lives. Contact with family and friends is encouraged and supported. Menus appear balanced and food looked appetising and served in pleasant surroundings. Stoneygate Ashlands DS0000006446.V320482.R01.S.doc Version 5.2 Page 13 EVIDENCE: Care plans were noted to be thorough, but do not identify, or address, personal preferences, such as “I like to get up at 8.00 am.” “I often wonder why I need to get up at 6.00am when I would love to get up around 8.30.” Others stated that they “had no choice as to when to go to bed, “I go when the night staff come on duty.” Staff on duty during the inspection though, insist that the service users start to use buzzers around 6.00am so that it why they get up then. This lack of personal preference, reduces the ability of service users to make choices about their daily lives, and could lead to agitation and frustration at not being able to be in control of their own day to day living. During the inspection the majority of service users were in the lounge areas, one was for smokers. The larger lounge had the television on in the corner, but this was controlled by the service users and was not intrusive, during the conversations. A game of bingo took place during the afternoon, and service users all said that they were “happy with the activities provided.” “I loved doing the Faberge-like eggs.” And crafts and cards were on display around the home. Other service users said, “You must have an interest and here I can follow my interest.” There were a number of books in the lounge “library”, and service users were observed reading these. Discussion with them evidenced that this was a regular activity and they loved to talk about the books they were reading. The shelves held a large variety of books, some in large print. Service users spoken with said they were happy with the level of activity provided and that there were a number of trips outside as well, which they enjoyed. The service users were “getting ready to have a Christmas party next week.” Visitors spoken with also said that their relatives were happy with the activities. They also said that they were made to feel welcome at any time and refreshments were offered during visits. They also said that Diane Smith was approachable, helpful and very professional in her care of their relatives. The menus seen were well balanced and varied and offered choices. The meal observed during the visit was appetising and served in a well-presented dining area. There were bowls of fresh fruit and jugs of various juices placed frequently around the home. Also, covered bowls with assorted biscuits were on the tables in the dining area and also placed around the communal rooms. Service Stoneygate Ashlands DS0000006446.V320482.R01.S.doc Version 5.2 Page 14 users were observed during the visit to, spontaneously, help themselves to these, with bins provided for the waste. Stoneygate Ashlands DS0000006446.V320482.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. 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. The manager responds appropriately to complaints about the service. There are good systems in place to protect service users from abuse. EVIDENCE: The home has in place policies and procedures to deal with complaints and service users spoken with said they were happy that they could complain to the manager, who always listens and deals with things quickly. Policies and procedures are in place for the safeguarding of adults and staff spoken with were aware of their responsibilities within the protection of vulnerable adults. They also said they had received training about abuse. New staff are supervised, after Protection of Vulnerable Adults check, and prior to receipt of enhanced Criminal Records Bureau checks, whilst working with service users. The head office receives the check results and then informs the home. This is then recorded in the staff file. Stoneygate Ashlands DS0000006446.V320482.R01.S.doc Version 5.2 Page 16 Service users spoken with said that they felt safe and secure within this home. One said “I sleep so much better now I am here, as I feel safe. I didn’t at home on my own.” Stoneygate Ashlands DS0000006446.V320482.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24, 25 & 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is well maintained, comfortably decorated and furnished and generally clean and hygienic. Security at the main entrance requires attention to reduce risks of intruders during times when the administration office is unmanned. Stoneygate Ashlands DS0000006446.V320482.R01.S.doc Version 5.2 Page 18 EVIDENCE: During the inspection it was noted that the outer main door was unlocked to allow free access for visitors and service users. But, when the administration office was unmanned, individuals could enter the building unnoticed. This could have implications on the safety of the service users, as access could be obtained to many areas of the home from this main entrance. The home was pleasantly decorated, with interesting pictures and ornaments around the communal areas. The crafts made by the service users were also displayed. All the communal lounges and areas were clean, and had a homely atmosphere. The toilets and bathing facilities were generally clean and hygienic. However, the downstairs shower/toilet had a bin without a lid, which contained soiled continence material, which could lead to infections if not removed. This area also had a selection of toiletries and a razor on the windowsill, which should have been put into service user’s own rooms, reducing the risks of harm to service users, particularly those with dementia. The service user’s own rooms were pleasant and contained personal items. The service users spoken with all said they were happy with their rooms. One service user said, “I love my room, especially now the builders are working, I can watch them working.” Stoneygate Ashlands DS0000006446.V320482.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the 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. The skill mix and number of staff members were sufficient to meet the needs of the service users. They are trained and competent to carry out their role and protect service users. Recruitment processes are in place to ensure service users in safe hands. EVIDENCE: During the inspection there were sufficient carers working to meet the needs of the service users. Service users spoken with said, “the staff are always helpful and come as soon as I need them.” Stoneygate Ashlands DS0000006446.V320482.R01.S.doc Version 5.2 Page 20 Staff files case tracked, contained evidence of Criminal Records Bureau checks, appropriate references and application forms. Training records were also inspected. These showed the care staff had received mandatory training including, Moving and Handling, COSHH, First Aid and Basic Food Hygiene, some had obtained National Vocational Qualifications. 7 members of staff have completed a National Vocational Training Qualification, with 4 others at present working on their award. The Assessor was present during the inspection. The manager also discussed the training department and also that the local District Nursing team were assisting with specialised training, including catheter care. One staff member spoken with said “You can’t escape the training.” Another said, “We get the training we need to do the work we have to do and more.” “The training makes me feel valued as part of a team,” was another comment made. Stoneygate Ashlands DS0000006446.V320482.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Stoneygate Ashlands DS0000006446.V320482.R01.S.doc Version 5.2 Page 22 The manager works hard to run the home in the best interest of the service users and has strong leadership skills, which support the staff and service users. The service users’ finances are appropriately administered. Staff are supervised and all are supported to ensure the health, safety and welfare of the service users and staff. EVIDENCE: The manager holds residents meetings to discuss ideas or concerns residents may have. Service users spoken with confirmed that these do take place, and that Diane Smith does listen at other times too. But, as evidenced previously, service users’ preferences are not always addressed within care plans, so their opinions and opportunities to make choices and decisions become limited. Prime Life Ltd have developed a good quality rating tool, using the 5 star system. This quality assessment is carried out by head office and looks at the Individual Care package, keyworker system, flexibility of when food served, finances, flexibility of daily living, pre-admission information social programmes and general atmosphere. This also contains service user comments. Evidence, in the form of a formal report from the head office, was seen during this inspection. Financial procedures were inspected and found to be in order and service users spoken with were satisfied with the way their financial affairs are dealt with. Staff spoken with said that they had regular, recorded, supervision and records were seen to evidence this is carried out appropriately. Records seen indicate that the required health and safety and maintenance checks are up to date and appropriately logged to promote the safety and welfare of the service users. Stoneygate Ashlands DS0000006446.V320482.R01.S.doc Version 5.2 Page 23 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 X 2 X 3 3 4 X 5 X 6 3 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 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 3 20 3 21 X 22 X 23 x 24 3 25 3 26 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 x 33 2 34 x 35 3 36 x 37 x 38 3 Stoneygate Ashlands DS0000006446.V320482.R01.S.doc Version 5.2 Page 24 none Are there any outstanding requirements from the last inspection? 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. 2 Standard OP7 Regulation 13, 15 Requirement The registered person must ensure the care plan includes any changes identified on review, and actions needed to meet the changes set out in the plan, together with the appropriate risk assessment, with particular attention to falls. Timescale for action 01/03/07 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. 3. 4. Refer to Standard OP7 OP14 OP25 Good Practice Recommendations To identify, within a care plan, the actions required to meet the needs of the service user. Service user care plans to include actions to maximise their personal choices and preferences. To risk assess the main entrance and administration office area, in particular when the office is unmanned and the outer door is unlocked. Ensure that all bins containing disposable continence products are covered and all toiletries removed from communal areas to avoid infection or harm to service users. DS0000006446.V320482.R01.S.doc Version 5.2 Page 25 OP26 Stoneygate Ashlands Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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. 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