Inspection on 31/08/06 for Ailwyn Hall Care Home

This inspection was carried out on 31st August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ailwyn Hall Care Home 13/08/07

Ailwyn Hall Care Home 13/12/06

Ailwyn Hall Care Home 23/08/05

Ailwyn Hall Care Home 05/04/05

Ailwyn Hall Care Home 21/09/04

Ailwyn Hall Care Home 22/04/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Ailwyn Hall Care Home Berry`s Lane Honingham Norwich Norfolk NR9 5AY Lead Inspector Ann Catterick Unannounced Inspection 31st August 2006 09:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ailwyn Hall Care Home DS0000055861.V311053.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. Ailwyn Hall Care Home DS0000055861.V311053.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ailwyn Hall Care Home Address Berry`s Lane Honingham Norwich Norfolk NR9 5AY 01603 880624 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@ashleycaregroup.com Gastank Ltd Position vacant Care Home 39 Category(ies) of Dementia - over 65 years of age (13), Old age, registration, with number not falling within any other category (26) of places Ailwyn Hall Care Home DS0000055861.V311053.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd August 2005 Brief Description of the Service: Ailwyn Hall is a care home providing personal care and accommodation for 39 older people, 13 of whom have dementia. The home comprises of two units Emily unit and Rosie unit. The home is owned by Gastank Ltd and the responsible individual is Ashley Oliver George. The home is located in the village of Honingham. The home is close to the main A47 providing easy access to both Norwich and Dereham. The home has 30 single rooms, 19 of which are en suite and 4 double rooms, 2 of which are en suite. The home has a passenger lift. The home is set in a picturesque setting in its own grounds surrounded by mature trees and well maintained gardens. The exterior of the home can be accessed by wheelchair users and provides a pleasant environment for service users in the summer months. There is parking to the front and to the side of the property. Ailwyn Hall Care Home DS0000055861.V311053.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection and the visit to the home took place over two days, the 31st of August and the 6th of September. Some information from the home was received before the visit and some information for the pre inspection questionnaire was received on the second day of the visit. Twenty-two comment cards were received from relatives. Most relatives felt that they were always welcomed into the home and that they could visit their relatives in private. Several relatives felt that the home did not have adequate staffing levels and several had made complaints about the service. The inspector was able to tour the premises, speak with the proprietor, deputy manager, administrator and care staff as well as look at care plans, staff files and policies and procedures. There was also opportunity to speak with service users, relatives and community health professionals. What the service does well: What has improved since the last inspection? The home has had a new bath installed. A part time administrator has now been appointed to the home. Processes around recruitment have improved. All bedroom doors on Rosie unit are now lockable. Some new bedroom furniture has been purchased. Ailwyn Hall Care Home DS0000055861.V311053.R01.S.doc Version 5.2 Page 6 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. Ailwyn Hall Care Home DS0000055861.V311053.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ailwyn Hall Care Home DS0000055861.V311053.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prior to admission prospective service users are assessed by the home and, if involved, a health or social care professional. Intermediate care is not offered in this home. EVIDENCE: The home completes an assessment prior to admission. The assessment is recorded on the care plan details and then further information is gathered when the service user is admitted. The consequence of this is that the initial assessment is incorporated within the care plan. It would be more appropriate to document a separated assessment that clearly identifies need and shows how the home can meet need. A recommendation has been made in this area. Ailwyn Hall Care Home DS0000055861.V311053.R01.S.doc Version 5.2 Page 9 Assessments are received from social and health professionals prior to admission. The home does not provide intermediate care. Ailwyn Hall Care Home DS0000055861.V311053.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care plans are not detailed enough to ensure the all of the health, personal and social care needs of individual service users are met. The home’s medication procedures do not fully ensure that service users are fully protected, however this can be easily put right. Service users are not always treated in a way that protects their privacy and promotes dignity. EVIDENCE: Several care plans were seen and the information in all was limited. The format of the care plans gives little opportunity for detailed recording. Some service users on Rosie unit have a diagnosis of dementia or were displaying behaviour that suggested they might have dementia. These service users need to be re assessed, as all dementia care placements are full. A requirement has been made in this area. If the outcome of the assessment Ailwyn Hall Care Home DS0000055861.V311053.R01.S.doc Version 5.2 Page 11 is that there are service users living in Rosie unit who have dementia and the proprietor wishes for them to remain in the home an application to vary the registration needs to be made. Nutritional information was limited and service users were not weighed on a regular basis. A service user who is visually underweight did not have a comprehensive nutritional plan and was not weighed on a regular basis. The inspector was informed that the home had no scales to weigh service users. A requirement has been made in this area. The home does not use a rolling menu and wastage is not monitored. There was not evidence on service users files of how the home could monitor food and liquid intake. This is particularly important for those service users with dementia. A requirement has been made in this area. In Emily unit several service users had a pressure mat placed by their bed. The electrical connection for this was the same as for the call bell and this meant that these service users did not have access to a call bell system. There were no risk assessments relating to this. If service users are unable to use the call bell system another system needs to be in place. This could be another form of assisted technology or it may mean staffing checking these service users on a very regular basis during the night. A requirement has been made in this area. A service user who had no sight spent her time in her room appearing to have no knowledge that she spent much of the time calling out. Within the room was a chart that staff signed when they went to into the room but it did not say what they did or how long they were in the room. Within the care plan there was no person centred plan of how the home cared for this lady’s individual needs. Where there were risk assessments with regard falls they were limited and inadequate. Within a one month period 44 incidents regarding slips trips or falls had been recorded. Nine of these incidents related to the same service user. Within her care plan her falls risk assessment had been reviewed and the only record was ‘no change’. Within the 12 month period between August 05 and September 06 126 incidents had been recorded. A requirement has been made in this area. Two community health workers were spoken to and they spoke positively about the health care received within the home. It was felt there had been improvement in this area. They were frequently contacted by the home if there was concern about a service user. Care plans have some information about how individual needs are met but are very limited, especially around social activity and emotional wellbeing. The deputy manager is aware that care plans are not good and the company plan to use a care plan format that has worked well within another home. A requirement has been made in this area. Ailwyn Hall Care Home DS0000055861.V311053.R01.S.doc Version 5.2 Page 12 Staff were observed administrating medication and this was done in a competent and safe way. The home has a practice of two staff always being involved in the administration of medication. Those staff administrating medication had received medication training. MAR sheets were fully completed. The home does not use the ‘bring forward’ facility on the MAR sheets and this makes it difficult to track the receipt, administration and disposal of medication. The home needs to ensure that there are arrangements for the recording, handling, safe keeping, safe administration and disposal of medicines. A requirement has been made in this area. The stock cupboard was seen and there was some evidence of over ordering and a recommendation has been made in this area. Within Emily unit most service users appear to spend most of their time in the large lounge/ dining area. Most bedroom doors are locked and service users are encouraged to remain in the lounge. Service users should have access to their own bedrooms and if there is an issue with service users going into other service users’ bedrooms this needs to be dealt with in another way. This is particularly relevant when communal space is limited. Risk assessments need to be carried out as different solutions may suit different service users. This practice affects service users privacy and dignity. A requirement has been made in this area. Ailwyn Hall Care Home DS0000055861.V311053.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Routines of daily living are not flexible or varied therefore offering no opportunity for service users to lead a varied and meaningful life. Relatives and friends are always welcomed into the home. There appears to be limited opportunity for service users to have choice and control within their own lives. The quality of the meals provided cannot be properly assessed and there are poor records relating to menus planning. EVIDENCE: On arrival at the home the inspector went straight to the dementia care unit, and asked staff what plans there were for activity and occupation for the day. Neither staff on duty had any plans to enable service users to become involved in any activity or occupation. Music was playing in the background and staff said that after breakfast service users were often sleepy. There appeared to be Ailwyn Hall Care Home DS0000055861.V311053.R01.S.doc Version 5.2 Page 14 no understanding of person centred work. Relatives spoken to on both days of the inspection commented on the lack of activity within the home. The home does not have any transport to take service users out of the home and there is poor access to the grounds. The needs of service users within the dementia care unit did not appear to have been identified within their care plan and the social and emotional needs of service users did not appear to be fully met. A requirement has been made in this area. Within Rosie unit music was playing during the morning of the inspection. This included White Christmas, which did not seem to be appropriate for the end of August. Those visitors spoken to on the day of inspection were speaking to their relatives within both of the communal lounges. Within the dementia care unit there is only one large room that is used as a dining room and lounge, therefore relatives are limited to where they meet with their relatives. Those relatives spoken to say that they were always made welcome in the home. Although the home had a menu plan at the front of the home this was not used in the kitchen. The cook on duty informed the inspector that menu planning is done every couple of weeks. This is an unsatisfactory system, as the nutritional intake of service users cannot be assessed. No consideration had been made with regard the special needs of service users with dementia although much has been written in this area. There was no way of monitoring intake as wastage was not assessed and there was no record of how much service users were eating. There was no menu board in the units to advice service users what was for lunch and there was no clear second choice automatically offered. The cook said that there is always a choice if service users do no like the first choice but this was not clear. Within the dementia care unit plastic mugs were used for drinks for all service users. Unless risk assessments have identified a risk with china cups or mugs there is no reason for service users to have these as it does not promote dignity nor is it usual for adults to drink from plastic mugs. A requirement has been made in this area. Ailwyn Hall Care Home DS0000055861.V311053.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure and this is used when a complaint is made. The home could not find any up to date adult protection policy for the home although they did have a copy of Norfolk’s local procedures. EVIDENCE: Evidence was seen of complaints received by the home and how they were dealt with. The system the home has is adequate. Comment cards from relatives suggested a significant amount of complaints had been made and this was confirmed by information received by the home. The home does not have an up to date policy and procedure with regard adult protection but does have a copy of the Norfolk policy and procedures. Training records do not indicate that any staff have had training in this area. Ailwyn Hall Care Home DS0000055861.V311053.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 24, 25 and 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Not all areas of the home are safe and well maintained. Appropriate signage was being used in the dementia care unit. Communal areas are adequate in part of the home but limited in other areas of the home. Service users do not all have access to communal space. This relates to the patio and garden areas. Some bedrooms, especially on the dementia care unit, were lacking in some furniture and those items that make a room appear homely. The home was not clean and odourless in all areas. Ailwyn Hall Care Home DS0000055861.V311053.R01.S.doc Version 5.2 Page 17 EVIDENCE: The home does not have a programme of maintenance and renewal, although there are plans to improve the environment. The home has lovely grounds but these are not easily accessible as paths are too narrow and much of the garden is shingle or laid to lawn. A service user commented upon this difficulty. A requirement has been made in this area. There is a patio area outside Emily wing and relatives informed the inspector that service users used this area when the weather was good. Communal space is limited. Within Rosie unit there is a large dining area and lounge. Within Emily unit there is a large room that is used as the lounge and dining area. There is opportunity to make the room into two areas but this was not how it was on the day of inspection and service users were sitting all around the room with no activity. The dining tables were pushed to the side of the room. It appeared that several service users ate their meals at their chair. Toilet and bathing facilities were adequate. There was no signage on Emily unit and all doors were the same colour. Some service users had their names on their doors but this was in small print and totally ineffective. A requirement has been made in this area. All unoccupied bedrooms on Emily unit were locked. The communal space on this unit is limited and apart from infringing on service users privacy and dignity the policy of locking bedrooms deprived service uses of private accommodation. A requirement has been made in this area. Bedroom doors needed oiling. The beds were inspected and some were not made properly being without top sheets and others without duvet covers, one bed had a pillowcase without a cover. Several of the bedrooms of Emily wing lacked a ‘lived in feeling’ with little in them that would familiar to the occupant. There were a couple of bedrooms that had a much more homely feel to them. The care in this area was not acceptable. A requirement has been made in this area. A couple who shared a room in Rosie Unit were spoken to and they were very satisfied with their accommodation. Bedroom sizes were generally good. Within Emily unit when testing a bedroom hot tap it took several minutes for the water to come through at a temperature warm enough for washing in. A tap at a bedroom sink and at a bathroom sink were too hot and in other areas there appeared to be no hot water. A radiator in the upstairs bathroom was not risk assessed or covered. Some windows on the first floor do not have window restrictors and no risk assessment have been completed. A requirement has been made in this area. In some areas of the home the lighting is dull and could present a risk to service users. Within Emily unit many areas had an unpleasant odour and relatives spoken to on the day of inspection confirmed that this was usual saying that it was often very strong and unpleasant. This is not acceptable and the home needs to ensure that this issue is dealt with. Domestic staff were spoken to and said Ailwyn Hall Care Home DS0000055861.V311053.R01.S.doc Version 5.2 Page 18 that although they shampooed carpets on a regular basis they could not ensure that the home smelt fresh at all times. Some bedroom carpets were not fit for purpose. A requirement has been made in this area. Ailwyn Hall Care Home DS0000055861.V311053.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There are not always sufficiently trained staff on duty to meet the needs of service users. Staff training is inadequate. EVIDENCE: The home has no manager although one has been appointed and it is planned that she commences work at the beginning of November. The rota does not identify the role of staff and what hour they are working. The needs of service users are not fully met and it can therefore be presumed that either there are not enough staff on duty or that the staff on duty do not have the appropriate skill or knowledge to meet need. Evidence of this was observed on the dementia care unit with some staff showing lack of insight into the needs of service users with dementia. A requirement has been made in this area. Forty five per cent of staff have NVQ level 2 or above. There was no evidence of formal supervision on file and speaking to staff confirmed that formal supervision does not take place. A requirement has been made in this area. Ailwyn Hall Care Home DS0000055861.V311053.R01.S.doc Version 5.2 Page 20 Those files inspected of recent employee had all relevant information. The home does not issue staff with the CSCC code of conduct. A recommendation has been made in this area. Staff receive induction although this is limited, being a tick list with no evidence of how competence has been achieved. Not all staff have received all mandatory training such as moving and handling, food hygiene, first aid or infection control. A requirement has been made in this area. Ailwyn Hall Care Home DS0000055861.V311053.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has no manager and this is evident in the poor quality of service being provided. No clear quality assurance system takes place. Money looked after is stored safely although minor adjustments to procedures have been recommended. The health, safety and well being of service users are not always protected. Ailwyn Hall Care Home DS0000055861.V311053.R01.S.doc Version 5.2 Page 22 EVIDENCE: The home has not had a registered manager for some time. A manager had been appointed but has recently left the home. There are significant shortfalls within the service and it is likely that this is a consequence of no competent registered manager. The proprietor has appointed a new experienced manager and it is planned that the new manager commences her post at the beginning of November. It has been recommended that the manager appointed has or plans to have a qualification within dementia care. A recommendation has been made in this area. In the interim period the deputy manager is taking responsibility for the home and an administrator from another home within the company has been employed at the home for two days a week. The previous manager had started a quality assurance system but this has not developed any further. The home needs to have a quality assurance system that audits the quality of the service. The findings would need to be presented in a form that can be published and an improvement plan made. A requirement has been made in this area. The home takes responsibility for looking after some service users money. This was inspected and three accounts audited and these were all correct. At present it is only one member of staff who has access to this money. The deputy manager does not sign the records and it has been recommended that the service user sign the record when able as well as the staff member completing the transaction. Staff were seen to move service users in a way that was not safe. A requirement has been made in this area. Although staff were involved in regular fire drills there was no recording of which staff were present therefore no way of knowing which staff have received the training. A requirement has been made in this area. The home had not been not been notifying the commission of any serious event other than the death of a service user. A requirement has been made in this area. There was no evidence to suggest that staff are receiving foundation training that meets the specification laid out by The Skills for Care. An example of this was that the deputy manager was aware her First Aid certificate had expired. A requirement has been made in this area. Ailwyn Hall Care Home DS0000055861.V311053.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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 1 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 1 1 x 2 x 1 1 1 STAFFING Standard No Score 27 1 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x 1 x 3 1 x 1 Ailwyn Hall Care Home DS0000055861.V311053.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 14 (2)(a)(b) Requirement The registered person must ensure that the assessed needs of service users are kept under review to ensure that the home can continue to meet any changing need. The registered person must ensure that care plans include all of those records identified in Schedule 3 of the Care Home Regulations 2001. The registered person must consult service users about the programme of activities arranged by or on behalf of the care home, and provide facilities for recreation including, having regard to the needs of service users, activities in relation to recreation, fitness and training. The registered person must ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. This relates in particular to the safety of service users on Emily unit who do not have access to a call bell. The registered person must take DS0000055861.V311053.R01.S.doc Timescale for action 01/12/06 2. OP7 17(1)a 01/12/06 3. OP7 16(2)n 01/12/06 4. OP7 13(4)c 01/12/06 5. OP9 13(2) 01/12/06 Page 25 Ailwyn Hall Care Home Version 5.2 6. OP10 13(4)(a) 7. OP15 16(2)i 8. OP19 23(2) 9 OP22 23(2)a steps to ensure medication records demonstrate that medication has been safely administered in line with prescribed instruction. This relates particularly to audit trails. The registered person must ensure that service users have the opportunity for privacy and that service users dignity is promoted and protected. The registered person must ensure that service users are provided with suitable, wholesome and nutritious food that is varied and properly repaired. This is a repeat requirement. The first action date being 01/05/05. The registered person must ensure that the physical environment meet the needs of service users. This relates particularly to the environment on Emily unit. The registered person must ensure that all communal areas of the home are accessible to service users. This relates particularly to the patio and path and garden areas. 01/12/06 01/12/06 01/12/06 01/01/07 10 OP24 16(c) 11 OP25 13(4)c The registered person must 01/12/06 ensure that the home provides adequate furniture, bedding and other furnishings to meet the needs of service users. The registered person must 01/12/06 ensure that all areas of the home that service users have access to have been appropriately risk assessed and arrangement made to minimise risk. This relates particularly to the concerns with regard water temperatures, window restrictors and the uncovered radiator in one of the upstairs bathrooms. DS0000055861.V311053.R01.S.doc Version 5.2 Page 26 Ailwyn Hall Care Home 12 13 OP26 OP27 16(k) 18 1(a) 14 OP30 18 (c) 15 OP33 26 (2) 16 OP38 13 (5) 17 OP38 23 4 (d) (e) The registered person must ensure that all areas of the home are free from offensive odours. The registered person must ensure that the home employs sufficient staff with the skill and qualifications to meet the needs of service users. The registered person must ensure that staff have the appropriate training to the work they are to perform. This includes induction and foundation training. The registered person must ensure that they ensure that monthly visits by the provider are made as advised in 26(4)(a) and a report written and sent to the Commission. The registered person must ensure that suitable arrangements and training for a safe system for moving and handling are made. The registered person must ensure that all staff working in the home receive suitable training in fire prevention, including staff drills and the names of staff attended. 01/12/06 01/12/06 01/12/06 01/12/06 01/12/06 01/12/06 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 OP3 OP20 Good Practice Recommendations That the assessment prior to admission be recorded in a separate form to the care plan. That the provider ensures that there are adequate dining tables and chairs to enable all residents to sit at the dining tables for meals if they choose to do so. DS0000055861.V311053.R01.S.doc Version 5.2 Page 27 Ailwyn Hall Care Home 3. 4 OP29 OP31 That all staff receive a copy of the General Social Care Council code of conduct leaflet. That when a manager is in post they consider the need for a qualification in dementia care. Ailwyn Hall Care Home DS0000055861.V311053.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 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 Ailwyn Hall Care Home DS0000055861.V311053.R01.S.doc Version 5.2 Page 29 - 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. 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