Inspection on 16/10/08 for Ainsworth Nursing Home

This inspection was carried out on 16th October 2008.

CSCI found this care home to be providing an Adequate service.

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

Ainsworth Nursing Home 22/04/09

Ainsworth Nursing Home 30/04/08

Ainsworth Nursing Home 27/11/07

Ainsworth Nursing Home 08/06/07

Ainsworth Nursing Home 02/02/07

Ainsworth Nursing Home 19/06/06

Ainsworth Nursing Home 08/03/06

Ainsworth Nursing Home 15/07/05

Ainsworth Nursing Home 06/09/04

Ainsworth Nursing Home 08/06/04

Ainsworth Nursing Home 02/02/04

Extracts from inspection reports are licensed from CQC, this page was updated on 06/02/2009.

CARE HOMES FOR OLDER PEOPLE Ainsworth Nursing Home Knowsley Road Ainsworth Bolton Lancashire BL2 5PT Lead Inspector Lucy Burgess Unannounced Inspection 09:30 16 October 2008 th 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 Ainsworth Nursing Home DS0000017312.V372827.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. Ainsworth Nursing Home DS0000017312.V372827.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ainsworth Nursing Home Address Knowsley Road Ainsworth Bolton Lancashire BL2 5PT 0161 797 4175 0161 797 2168 d.subbiah@btconnect.com 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) Ainsworth Nursing Home Ltd Manager post vacant Care Home 37 Category(ies) of Dementia - over 65 years of age (6), Mental registration, with number disorder, excluding learning disability or of places dementia (7), Mental Disorder, excluding learning disability or dementia - over 65 years of age (3), Old age, not falling within any other category (19), Physical disability (2) Ainsworth Nursing Home DS0000017312.V372827.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 37 service users, to include: Up to 19 service users in the category of OP; Up to 2 service users in the category of PD (Physical Disabilities under 65 years of age); Up to 6 service users in the category of DE(E) (Dementia over 65 years of age); Up to 7 service users in the category of MD (Mental Disorder under 65 years of age); Up to 3 service users in the category of MD (E) (Mental Disorder over 65 years of age). The service should employ a suitably experienced and qualified manager who is registered with the Commission for Social Care Inspection. It has been agreed with the registered persons that Ainsworth Nursing Home will work towards the following categories to ensure three specific areas of care provision at the Home, to improve the quality of care provided by the service, without disruption to existing service users: Up to 19 service users in the category of OP Up to 2 service users in the category of PD (Physical Disabilities under 65 years of age); Up to 10 service users in the category of DE(E) (Dementia over 65 years of age); Up to 6 service users in the category of MD (Mental Disorder under 65 years of age). From 3rd July 2008 there shall be no further admissions of service users to Ainsworth Nursing Home without the prior written agreement with the Commission for Social Care Inspection. 30th April 2008 2. 3. 4. Date of last inspection Brief Description of the Service: Ainsworth Nursing Home is a care home providing nursing and residential care for older people including older people with mental health and dementia needs. The building is a large, converted former hospital. It is detached and set within its own extensive grounds, with lawned areas and mature trees and shrubs. It is situated at the end of a private access road, in a semi-rural location within the Ainsworth area of Bury. The current fee for this service ranges from £369 to £508 per week dependent on the level of need and funding arrangements. Ainsworth Nursing Home DS0000017312.V372827.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was a second key inspection carried out by 2 inspectors, which included a site visit and took place over one day, for a period of 9 hours. The service did not know that the inspectors were going to visit. During the inspection care and medication records were looked at as well as information about the staff and health and safety including how the home and the equipment were kept safe. The inspectors also looked around the building. As part of the inspection process the provider’s are asked to complete a selfassessment survey information document (Annual Quality Assurance Assessment). This was sent to the home before the inspection and had been completed by the deputy manager and returned to us prior to the site visit. Other information was gathered from the feedback surveys we sent out. We received completed surveys from 2 members of staff. We also spent time speaking with people, a relative, visiting health professionals and staff as well as observing practice. Comments have been added to the report. At present placements are not being made at the home due to issues which arose in relation to the standard of care provided at the home. From July 2008 we imposed conditions to restrict any further placements at the home without prior permission from the commission. Regular visits have been made by us and the local authorities to monitor the standard of care provided and review the improvements being made at the home. Discussion and feedback was held with the new manager and Providers. What the service does well: The majority of the nursing and care staff have remained the same offering stability in the support being provided. Feedback was received from people who live at the home. The following comments were made: The new manager is lovely and There is a big difference to what it was before. It is more organised. One visitor commented that it was: 1st Class. Ainsworth Nursing Home DS0000017312.V372827.R01.S.doc Version 5.2 Page 6 In the surveys where staff are asked what the service does well, comments included; we provide a good quality of life for each service user and I think the service does well in caring for all the clients needs. One person also said, I think all the management and staff work very well together and we all do our best to see that clients needs are met. What has improved since the last inspection? What they could do better: The manager must ensure that application to register with us is made as soon as possible. On-going improvements to enhance the appearance of the home need to continue so that people live in comfortable and pleasant surroundings. Those staff yet to receive adult protection training must do so to ensure that they are aware of the procedure to follow in cases of alleged abuse. A programme of training must be provided including NVQ’s ensuring all staff are equipped with the knowledge and skills needed to meet the specific needs of people living at the home. All staff including ancillary staff should receive regular supervision and support to promote their continued professional development. Action identified on the gas safety certificate needs to be addressed making sure the system is safe and people are not at risk. An up to date fire risk assessment needs to be available in the home so that staff can refer to it and are aware of what action to take should an incident occur. Water temperatures should be regulated and maintained at 43°C for the safety and comfort of people living at the home. Ainsworth Nursing Home DS0000017312.V372827.R01.S.doc Version 5.2 Page 7 Information gathered as part of the quality monitoring process should be used to inform the homes annual development plan. A copy of this should be sent to the commission. An up to date fire risk assessment needs to be available in the home so that staff can refer to it and are aware of what action to take should an incident occur. 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. Ainsworth Nursing Home DS0000017312.V372827.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ainsworth Nursing Home DS0000017312.V372827.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems are in place to assess the needs of people, however no new placements are being made at the home without prior permission of the CSCI. This is to ensure that people can be cared for safely. EVIDENCE: Prior to our first inspection in April 2008 placements made by the local authorities had been suspended due to concerns, which had been raised about the care of people living at the home. This suspension is still in place and therefore no new people have moved into the home. Due to this we were unable to review any new assessment information gathered prior to people coming to live at the home. The new manager did explain the process she would follow when referrals are made to the home. This would include visiting the person to gather the necessary information as well as speaking with relatives and any health and social care professional involved. People would also be offered the opportunity Ainsworth Nursing Home DS0000017312.V372827.R01.S.doc Version 5.2 Page 10 to visit and spend time at the home so that they could meet other people and the staff. This would enable the person and the home the opportunity to make an informed decision about whether they would be able to meet their needs. Standard 6 is not applicable to this service, as they do not provide intermediate care services. Ainsworth Nursing Home DS0000017312.V372827.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans show what care needs the residents have and care practices ensure that their needs are met in a safe and caring way. EVIDENCE: Individual resident care records, (called care plans) were in place for each resident. The care plans of 2 of the residents were looked at. There had been an improvement in the way that the care plans were being written. They had a lot more information in them to show how the care needs of the residents were to be met. They also contained lots of details about what the residents were able to do for themselves. The staff looked at whether or not there was any risk in relation to the residents developing pressure sores, any risk of falling and also if they were at risk due to problems with their food and fluid intake. They also looked at and they wrote down, how any resident was to be assisted with being moved around and by how many members of staff and what equipment, if any, was to be used to assist in safe moving and handling. Ainsworth Nursing Home DS0000017312.V372827.R01.S.doc Version 5.2 Page 12 We saw that residents were weighed regularly and their weight was recorded in their care notes. We saw that staff wrote in the care plans when the residents had received visits from health care professionals, such as dentists, opticians, district nurses, nurses who specialise in wound care and chiropodists. Two of the residents had quite a lot of care needs so we went to see them in their bedrooms. We saw that in their bedrooms all the correct type of equipment was in place to make sure that they were looked after properly. A comment from one of the residents was: I like the manager, she just gets on with it. A visitor commented: No complaints at all. She is well looked after. We looked at the system for managing the medicines. On the last inspection we only looked at the medicine system on the dementia unit. A safe system was in place, so on this inspection we concentrated on the general side. Once again a safe system of managing the medicines was in place. The qualified nurses are the only people allowed to have responsibility for managing the medicines. Medicines and Controlled drugs were stored securely and recorded accurately. The residents looked clean and well cared for. We saw one staff member talking with a resident in a friendly and respectful way, although there was plenty of friendly banter. We saw staff knocking on bedroom and toilet doors and waiting where possible for an answer, before they went in. Ainsworth Nursing Home DS0000017312.V372827.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are supported and encouraged by staff to make choices about what they do, so that they can find enjoyment and satisfaction in their daily life. The residents are given a choice of well-balanced and nutritional meals. EVIDENCE: The residents’ routines of daily living and what they liked to do were written down in their care plans. The resident that we spoke to told us that she can, more or less do as she pleases and that she is not made to do anything that she does not want to. We saw some residents sitting in the lounge areas and others spending time in their bedrooms. The residents we spoke to in the conservatory told us that they were quite happy staying in there watching television. An activities organiser now works at the home for 4 days of the week and we saw a list of “what is going on” displayed in the lounges and in the entrance hall. A Bonfire party had been planned and a notice was displayed inviting people to go along and join in the fun. We saw some of the residents enjoying Ainsworth Nursing Home DS0000017312.V372827.R01.S.doc Version 5.2 Page 14 a reminiscence activity. One resident was listening to a staff member reading the newspaper to him. We saw visitors coming and going throughout the day and they seemed to know the staff very well. We did not eat with the residents but saw what they were having for lunch. The tables were nicely set with tablecloths, napkins and cruets. The meal served looked appetising, nutritious and there was plenty of it. The residents have the main meal at lunchtime and the lighter meal in the evening. We looked at the menus. The residents have a choice of meal at breakfast, lunch and tea. Hot and cold drinks were served throughout the day and during mealtimes. We looked at the food stocks in the kitchen and food stores. Dry, fresh and frozen food stocks were plentiful. Ainsworth Nursing Home DS0000017312.V372827.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Action has been taken to address areas of concern, which have been raised about the standard of care provided at the home. Staff training however is still required ensuring they follow the procedure should an allegation be made, making sure people are safe. EVIDENCE: As already identified serious concerns have been raised in relation to the care provided at the home. Due to this regular visits have been made by us and health and social care professionals to monitor and review the standard of care and progress required. During these visits and during this inspection improvements have been found. Following the initial investigation the provider has now made a referral to the Protection of Vulnerable Adults register. Those involved with the strategy team are still investigating a further complaint raised by the relatives of someone who lived at the home. We had also previously identified concerns about the staff team and their understanding of the local authority safeguarding procedure and whistle blowing. Someone has spoken to trained staff from the Royal College of Nursing about their responsibilities in line with their code of practice. Training records were also looked at. Of the current 34 care and ancillary staff, there was no evidence to show that 10 members of the team still have not received the relevant training. This was identified during the first key inspection carried Ainsworth Nursing Home DS0000017312.V372827.R01.S.doc Version 5.2 Page 16 out in April 2008 and must be addressed so that staff are aware of the procedure to follow should an allegation be made. Ainsworth Nursing Home DS0000017312.V372827.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Further improvements are needed to enhance the appearance as well as improve the overall standards within the home so that people live in a pleasant, comfortable and well maintained home. EVIDENCE: Following our visit in April 2008 we identified that a lot of work was needed to improve the standard and physical appearance of the home. During a random inspection carried out in July 2008 we found that redecoration had commenced, some carpets had been replaced and some new furniture had been purchased. Further improvements were found during this visit. This included, new carpeting to the main corridor on the dementia unit, new windows had been fitted in the kitchen and some bedrooms and the conservatory and bathrooms had been painted. Further work was planned to other communal areas. Ainsworth Nursing Home DS0000017312.V372827.R01.S.doc Version 5.2 Page 18 In order to bring the home up to a good standard further improvements are still needed including a number of bedrooms still need to be redecorated and old broken furniture replaced and the kitchen cupboards, which are worn, and doors need re-hanging or replacing. The standard of hygiene had also improved. Staff hand washing is provided as well as protective clothing. Staff were observed wearing this throughout the day. Rooms appeared cleaner and free from odour as too were the kitchen and appliances. Designated staff are in place and take responsibility for carryout the laundry and domestic tasks. Ainsworth Nursing Home DS0000017312.V372827.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Safe recruitment procedures are followed ensuring people are not placed at risk. However staff training and development needs to be improved ensuring staff have the competence and skills needed to fully meet the needs of people living at the home. EVIDENCE: Information was looked at in relation to staffing arrangements. At present there are 22 people living at the home, 15 people on the nursing and residential unit and 7 people on the dementia unit. Information on the rotas showed that staffing levels comprise of 2 nurses and 4 carers covering both units. The manager explained that she has spoken with regards to identifying designated teams for each of the units so that more continuity in care can be offered. In relation to night cover we have previously found that some days staffing comprised of 1 nurse and 2 carers or 1 nurse and 3 carers. Due to the current occupancy levels the provider feels that this is sufficient and that the needs of people living at the home can be safely met. At present the team comprises of the manager, deputy manager, 8 nurses including the manager, 16 care staff, 2 cooks, 2 kitchen assistants, 2 laundry Ainsworth Nursing Home DS0000017312.V372827.R01.S.doc Version 5.2 Page 20 staff, 3 domestic staff, an activities co-ordinator and a handyman. Agency cover has been used where necessary however this has been minimal. From observations made staff were more visible in communal areas interacting and supervising people. In relation to staff recruitment information was not looked at as no new staff have been employed. No issues were found during our previous visits. We discussed with the provider action taken following the dismissal of one member of staff due to gross misconduct. As agreed information has been passed on to the adult safeguarding co-ordinators for Bury and Bolton Local Authority as well as a referral to the Protection of Vulnerable Adults register. During previous visits major shortfalls have been found with regards to staff training and supervision. The manager has recently met with staff from the local training partnership group to discuss the training needs of the service. There was also correspondence of courses confirming places had been booked for some members of the team between November 2008 and March 2009. The manager needs to develop a programme of training addressing the specific training needs of staff. Progress in this area must be made as records showed that those staff identified during the previous key inspection have still not received any training. Without this there is no assurance that staff have the skills and competence needed to fully meet the needs of people living at the home. One staff member commented in the surveys, carers need to work more as a team and demonstrate the skills that they have received training for. Further training has been provided with regards to national vocational qualifications (NVQ). There are currently 16 care staff, of these 8 have already achieved level 2/3 and another one is completing the course. The manager also advised us that relevant NVQ’s are to be arranged for kitchen staff. In the surveys where staff are asked what the service does well, comments included; we provide a good quality of life for each service user and I think the service does well in caring for all the clients needs. One person also said, I think all the management and staff work very well together and we all do our best to see that clients needs are met. Ainsworth Nursing Home DS0000017312.V372827.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A period of stability within the management team is needed to ensure that staff are supported and directed in carrying out their duties and that people living at the home receive a quality service, which meets their needs. EVIDENCE: A new manager has now been appointed and took up post at the beginning of September 2008. The manager is nursed qualified, having worked within a hospital environment before moving to the private sector. Since 1995 she has held a management position working in homes for the elderly including nursing and dementia care. We were advised that the manager is in the process of completing the application to register with us. This must be done without delay. Ainsworth Nursing Home DS0000017312.V372827.R01.S.doc Version 5.2 Page 22 Since our last key inspection the providers and new manager have made a number of improvements throughout the home. These have included better hygiene standards, more detailed information about the care and support needs of people and improvements within the environment. The home will continue to be monitored to ensure that these and further improvements are made and sustained so that a good standard is provided throughout. In relation to quality assurance, systems for monitoring the service are being developed. The manager is utilising weekly and monthly monitoring forms, which explore records, training, staffing, environment and medication. There was evidence where action had been identified that items had been followed up and where necessary the relevant action taken. The new manager has also met with staff to discuss what needs to be done within the home as well as meeting with some relatives to discuss any issues they may have. The provider has also carried out monthly monitoring visits in line with regulation 26. Copies of these reports are held at the home and have been forwarded to us. The provider has also been providing information on a regular basis with regards to what action has been taken to address the requirements made during our previous visits. The system for the safekeeping of residents’ money was safe. Individual records are made of any money left in an account for the residents and any money spent on their behalf. Receipts are kept for any purchases made. Arrangements are now in place so that people have their own bank accounts. If people deposit money for their relative they are given a receipt. In relation to staff supervision, these sessions have now commenced. Although the manager has only been in post approximately 7 weeks she has formally met with 24 staff and discussions have been recorded. A team meeting has also been held and was attended by a large number of staff. The manager must ensure that all supervision and support includes ancillary staff. This is to ensure all staff are provided with clear direction and support and are made fully aware of their responsibilities so people living at the home are supported and cared for in a way, which ensures their safety. A random sample of safety certificates were examined. This included the 5year electric certificate, emergency lighting, gas safety and fire equipment. Action had been identified on the gas safety certificate. Whilst there was evidence that some areas had been addressed this did not include everything. This should be followed up ensuring all necessary action has been taken so that people are not placed at risk. The fire risk assessment seen was also out of date. We were told that this had been updated however was not provided. This information needs to available to staff so that they are aware of the arrangements in place ensuring people are safe. Ainsworth Nursing Home DS0000017312.V372827.R01.S.doc Version 5.2 Page 23 The home also employs a handyman who carries out the weekly/monthly checks to the fire alarm, emergency lighting, equipment and exits. Further checks are made in relation to water temperature checks. In a number of areas readings were below the temperature required. Arrangements should be made to ensure that these are regulated and maintained at a safe temperature for the comfort of people living at the home. Ainsworth Nursing Home DS0000017312.V372827.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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 Ainsworth Nursing Home DS0000017312.V372827.R01.S.doc Version 5.2 Page 25 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 OP18 Regulation 13(6) 18(1) Requirement All staff must receive training in relation to safeguarding adults making sure that they are clear about the procedure to follow should an allegation be made. (Outstanding requirement 30/7/08 & 30/10/08) On-going redecoration and refurbishment must be completed to ensure that the home is of a good standard providing comfortable well maintained accommodation for people to live. (Outstanding requirement 30/6/08 & 30/10/08) Timescale for action 30/01/09 2. OP19 16(2) 30/03/09 3. OP30 18(1) A programme of training must be 30/12/08 developed including NVQ’s so that staff have the knowledge and skill needed to meet the needs of those people who live at the home. Action identified on the gas safety certificate must be addressed making sure the system is safe and people are not at risk. 30/12/08 4. OP38 13(4) 23 Ainsworth Nursing Home DS0000017312.V372827.R01.S.doc Version 5.2 Page 26 5. OP38 13(4) Water temperatures must be regulated and maintained at 43°C for the safety and comfort of people living at the home. 30/12/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP30 Good Practice Recommendations The manager needs to ensure that staff have the competence and confidence in carrying out their duties and that knowledge and skills learnt through training are applied ensuring good practice at all times. The manager must ensure that application to register with us is made as soon as possible. Information gathered as part of the quality monitoring should be used to inform the homes annual development plan. A copy of this should be sent to the commission. Supervision session should be undertaken with all ancillary staff ensuring they are given the direction and support needed in carry out their duties. An up to date fire risk assessment needs to be available in the home so that staff can refer to it and are aware of what action to take should an incident occur. 2. 3. OP31 OP33 4. OP36 5. OP38 Ainsworth Nursing Home DS0000017312.V372827.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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