Inspection on 06/09/04 for Ainsworth Nursing Home

Care Home For Older PeopleAinsworth Nursing HomeKnowsley Road Ainsworth Nr Bolton Lancashire BL2 5PTAnnounced Inspection6th 8th 17th & 28th September 2004 7th October 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Ainsworth Nursing Home Address Knowsley Road, Ainsworth, Nr Bolton, Lancashire, BL2 5PT Tel No: 0161 797 4175 Fax No:Email address Name of registered company Ainsworth Nursing Home Ltd - Mrs Pooganthai Subbiah ­ Responsible Individual Name of registered manager Ms Brenda Jean Williams ­ see main body of the report. Type of registration Care Home No. of places registered (if applicable) 41Categories of registration, with number of places Mental disorder, excluding learning disability or dementia (20), Old age, not falling within any other category (20), Physical disability (2) Registration number F060000416 Date first registered Date of latest registration certificate 30th July 2002 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspection 16th April 2004 YES NO 08.06.04 If Yes refer to Part CAinsworth Nursing HomePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector Name of inspector Name of specialist (e.g. Interpreter/Signer) (if applicable) 1 2 3 46th September 2004 09:30 am Julie Bodell Stephanie West Pharmacist Thomas Merry - HSEID Code076213 ­ CSCIName of establishment representative at the time of inspectionBrenda Williams ­ Registered Manager Mrs Subbiah ­ Responsible Individual Doctor Subbiah ­ Director Sam Uppiah ­ RGN Acting ManagerAinsworth Nursing HomePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementAinsworth Nursing HomePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Ainsworth Nursing Home. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Ainsworth Nursing HomePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. 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 private access road, in a semi-rural location within the Ainsworth area of Bury.Ainsworth Nursing HomePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) At previous inspection visits, many care practices issues have been raised. The inspector acknowledges the efforts made by the staff team in addressing these matters. However progress had slowed down markedly at the time of the last inspection in June 2004. This was said to be due to an investigation at the Home, which was not founded. At that time the inspector stated that outstanding matters needed to be addressed as a matter of urgency. At the start of this inspection on 6th September 2004, the registered manager became ill and later sadly died. The inspector passed on her commiserations to the registered provider, director, service users and the staff team. Due to these circumstances the inspection took place over a number of visits throughout September and October 2004, including a pharmacist inspection. Many requirements remain outstanding. Choice of Home (4 standards were assessed and 2 were met) As a result of ongoing issues in respect of numbers and categories of service users placed at Ainsworth changes have been agreed with the provider about conditions of registration. A new certificate will be issued to reflect the conditions. The statement of purpose and service user guide must be reviewed and revised to reflect the certificate. Once in place then the registered provider must ensure the Home has the capacity to meet the service users assessment of need rather than an admission being made on the availability of a place. The Home must adhere to the registered numbers and categories at all times. Health and Personal Care (4 of the standards was assessed and 2 were met) A CSCI pharmacist inspected the Homes administration of medication system. A number of requirements were made. Daily Life and Social Activities (The 3 standards assessed 1 was met) Activities for service users need to be resumed as soon as possible. Complaints and Protection (3 standards assessed none were met) The complaint procedure must be reviewed and revised and made available to service users and their representatives. The Adult Protection procedures also need to be reviewed and revised and staff members provided with necessary training. Environment (7 of the 8 standards assessed were not met) The inspector identified a significant number of concerns regarding health and safety issues around the present laundry arrangements. These include control of infection, moving and handling and staff members personal safety. There are also outstanding fire safety issues. Staffing (3 of the 3 standards assessed were not met) Staff recruitment procedures need to comply with the Regulation to ensure safe practice. There is a need to develop formal induction training and supervision systems. Management and Administration (4 of the 4 standards assessed were not met) Monitoring issues on the part of the registered provider need to be improved in line with the Regulations. A registered matron/manager is required as a matter of urgency at Ainsworth.Ainsworth Nursing HomePage 6 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action 1 6 OP1 That the statement of purpose and function and service user guide is reviewed and revised and a new certificate is issued. That the currently agreed registered numbers and categories are adhered to with in each defined area within the Home. The range & frequency of social activities continues to be developed, particularly for those service users with dementia/confusion and records maintained. That a complaints procedure is established in accordance with this regulation. That the Homes Adult Protection procedure is developed further. That all staff members are trained in Adult Protection procedures including their responsibilities in relation to whistle blowing. That well-worn bedding is replaced, on both wings. 30.07.04 Immediate and ongoing.24OP4316OP1230.07.04422OP16Immediate and ongoing. 30.07.04513OP18613OP1830.07.047 8 9 1016 23 13 19OP19 OP21 OP26 OP2930.07.04That the issues relating to the toilet at the ramp 30.07.04 area of Manon Wing are addressed. That the present laundry arrangements are Immediate. reviewed as a matter of urgency. That a copy of any training certificates or professional qualifications must be kept. Immediate and ongoing.Ainsworth Nursing HomePage 7 1119OP29The format of the Homes application form is amended to give an applicants full work history and also identifying any gaps. That a reference must be taken from the past employees past employers and not an excolleague. That a thorough induction training programme is developed for new employees and a record maintained. That all staff members receive training in all areas identified in this Regulation. That any training attended should be detailed in staff members individual training record sheets That a review of the quality of care is produced. That the registered person visits the Home unannounced on a monthly basis in accordance with the Regulation.Immediate and ongoing. Immediate and ongoing. 30.07.04 30.07.04 30.07.041219OP2913 14 1518 13 18OP30 OP30 OP301624OP3330.07.0417 1826 18OP33 OP3630.07.04A formal staff supervision system needs to be 30.07.04 put in place that meets with Standard 36. That the efficiency of the present 19 17 OP37 30.07.04 administrative arrangements is reviewed. That a full assessment of the Homes policies 20 17 OP37 30.07.04 and procedures is undertaken. Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard 1 2 OP17 OP18 That information relating to independent advocacy schemes is made available to service users and there relatives. That a copy of No Secrets and a copy of the Local Authority Adult Protection procedure are acquired.CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)Ainsworth Nursing HomePage 8 Ainsworth Nursing HomePage 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1 6 OP1 That the statement of purpose and function and service user guide is reviewed and revised to reflect the new registration certificate. That the currently agreed registered numbers and categories are adhered to within each defined area of the Home. That the manager must ensure that all medication records are complete, accurate and up-to-date. Any changes must be clearly referenced and there should be no crossingout or overwriting in the CD register. That medication with a reduced `in-use shelf life must not normally be used for extended periods. That the storage areas must be tided and any expired, unlabelled or discontinued or otherwise unwanted medication must, with the service users permission, be returned promptly to the pharmacy for destruction. Medication should where possible be stored within the Clinical room. That the refrigerator temperature must be adjusted to ensure the correct operating temperature is maintained. 30.11.0424OP4Immediate and ongoing.317OP908.11.04413OP908.11.04513OP908.11.04613OP908.11.04Ainsworth Nursing HomePage 10 713OP9That a separate supply of `Homely Remedies must be obtained. Medication prescribed for other service users cannot be used as if it were homely remedy stock. That medical equipment is appropriately stored to ensure protection from infection. The range & frequency of social activities continues to be developed, particularly for those service users with dementia/confusion and records maintained. That a record of food provided for service users is maintained and retained for inspection for one year. That the cupboards under the sinks are replaced as required by the environmental health department. That a portable fridge thermometer is purchased for a freezer as required by the environmental health department. That a complaints procedure is established that fully meets with the requirements of this regulation. That the Homes Adult Protection procedure is developed further. That all staff members are trained in Adult Protection procedures including their responsibilities in relation to whistle blowing. That well-worn bedding is replaced, on both wings. The chair in C12A needs to be replaced. That the significant malodour problems in bedrooms C9 and C14 are addressed. That bedroom numbers C2, C11 and C14 need repainting. That the main corridor needs repainting. That the corridor carpet is intensively cleaned. That more washable armchairs are purchased for throughout the Home.08.11.04813OP10Immediate and ongoing.916OP1208.11.041017OP15Immediate and ongoing. 08.11.041113OP151213OP1508.11.041322OP1608.11.041413OP1808.11.041513OP1808.11.0416 17 18 19 20 21 2216 16 16 23 23 23 16OP19 OP19 OP19 OP19 OP19 OP19 OP1931.12.04 31.12.04 08.11.04 31.12.04 31.12.04 31.12.04 31.12.04Ainsworth Nursing HomePage 11 23 24 25 2616 16 16 23OP19 OP19 OP19 OP19That in bedroom C7 a washable surface is put around the walls of the bed to assist with cleaning and a vinyl floor covering put in place of the carpet. That old and damaged furniture continues to be replaced. That the mattress to M10 is replaced. That all outstanding items identified on the Fire Officers reports must now be addressed and the homes fire risk assessment must now be addressed. That all staff and service users are trained in evacuation procedures and are made aware of changes and this is evidenced. That where requested or needed the fitment of automatic door release mechanisms are put in place. That the recently established quiet area/lounge/meeting room that has been turned into a second office for the registered provider must revert back to the intended purpose for the use of service users. That the issues relating to the toilet at the ramp area of Manon Wing are addressed. That the badly rusting commode chair in the shower room on the nursing and residential side is replaced with a shower chair that is fit for the purpose. That the appropriateness of a chair being used by a service user in terms of safety, comfort and potential pressure is assessed by a suitably qualified professional person as soon as possible. That where double rooms are being used, as singles without the service users knowledge then the contract must be adhered to until the room becomes vacant again. That the replacement of windows needs to be extended to bedrooms on Cyrano, particularly those to the rear of the Home that are in poor condition, ill fitting and a security problem in some cases. That as specified in an improvement notice issued by an inspector from HSE on 08.09.04, window restrictors are placed in first floor bedrooms. That adequate ventilation is available in the internal laundry.30.11.04 Ongoing. 30.11.04 Immediate and ongoing. Immediate and ongoing. 30.11.042723OP192823OP192916OP2008.11.0430 3123 16OP21 OP2131.12.04 30.11.043213OP2208.11.04335OP23Ongoing.3423OP2431.12.0435 3613 13OP24 OP2608.10.04 30.11.04Ainsworth Nursing HomePage 12 37 38 39 40 41 42 43 4413 23 13 23 23 23 13 13OP26 OP26 OP26 OP26 OP26 OP26 OP26 OP26That the external laundry is heated to a temperature of 16 degrees Celsius during working hours. That sufficient space is available for sorting, folding and ironing of clothes. That a suitable trolley be provided for the collection and movement of linen. That the paved area to the external laundry is improved so that it is level and free from trip hazards. That all electrical fittings and fixtures in the external laundry meet NICEIC standards and are validated by a certificate. That the Fire Officers recommendations are met in respect of the external laundry. That clinical waste is stored in identifiable lockable bins whilst waiting for disposal. That all staff members handling clinical waste are provided with disposable gloves and aprons. That all staff members including domestics receive control of infection training and that this is evidenced. That the practice of leaving both the laundry trolley and clinical waste at the back door lobby cease as this is a means of escape. That adequate domestic staffing levels are provided at the Home at all times. That a review of the present care staffing arrangements conducted to ensure that all service users needs can be met and that continuity of care is provided. That a copy of any training certificates or professional qualifications must be kept. The format of the Homes application form is amended to give an applicants full work history and also identifying any gaps. That a reference must be taken from the past employees past employers and not an excolleague. That a thorough induction training programme is developed for new employees and a record maintained.30.11.04 30.11.04 30.11.04 30.11.04 30.11.04 30.11.04 30.11.04 Immediate and ongoing. 08.11.04 Immediate and ongoing. Immediate and ongoing 30.11.04 Immediate and ongoing. Immediate and ongoing. Immediate and ongoing. 30.11.044513OP264613OP264718OP264818OP274919OP295019OP295119OP295218OP30Ainsworth Nursing HomePage 13 53 5413 18OP30 OP30That all staff members receive training in all areas identified in this Regulation. That any training attended should be detailed in staff members individual training record sheets30.11.04 30.11.04558OP31That a registered matron/manager with all the necessary competencies be appointed as Immediate. soon as possible. That a review of the quality of care is produced. That the registered person visits the Home unannounced on a monthly basis in accordance with the Regulation. A formal staff supervision system needs to be put in place that meets with Standard 36. That the efficiency of the present administrative arrangements is reviewed. That a full assessment of the Homes policies and procedures is undertaken. 30.11.045624OP3357 58 59 6026 18 17 17OP33 OP36 OP37 OP3730.11.04 30.11.04 30.11.04 30.11.04RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * 1 2 3 OP17 OP18 OP26 That information relating to independent advocacy schemes is made available to service users and there relatives. That a copy of No Secrets is acquired. Consideration should be given to raising the washing machines and dryers from floor level so the doors are more easily accessible Page 14Ainsworth Nursing Home * Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Ainsworth Nursing HomePage 15 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES YES YES YES YES NO NO YES YES YES YES YES YES YES YES YES YES NO YES 5 2 0 YES YES YES NO 14 3 06/09/04 09:15 26.30Ainsworth Nursing HomePage 16 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Ainsworth Nursing HomePage 17 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) 438.50 To (£) 293.50Any charges for extras If yes, please state what the extras are:YESHAIRDRESSING CHIROPODY NEWSPAPERS OUTINGS 1 Key findings/Evidence Standard met? The present certificate does not accurately reflect the situation at the time of the inspection. At a meeting held on 01.09.03 it was decided that following variations that were being undertaken at the time an application would be made to amend the certificate to up to 37 service users to include 6 service users with a mental disorder (conservatory area), 11 service users with dementia (EMI Unit - Manon) and 20 older people with nursing or social care needs (Cyrano and annex). This will identify three discreet specialist areas within the Home. The inspector is aware that those areas are currently mixed, but every effort must now be made to admit within those areas those service users with an appropriate assessment. Following a discussion with the responsible individual and a fellow director, on 17.10.04 a letter has now been received from Ainsworth Nursing Home Ltd requesting a variation. Discussion has taken place on this and an agreement has been reached as to conditions. The statement of purpose and service user guide needs to be reviewed and revised to reflect the conditions. A new certificate will be issued.Ainsworth Nursing HomePage 18 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 3 Key findings/Evidence Standard met? At the last inspection it was requested that a number of amendments be made to the contract to bring it in to line with Standard 2 and inclusion of a trial period, terms of notice and provision for a third party signature for either a relative or social worker. This matter has now been addressed.Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? The inspector examined a number of service user care files at random and all were found to contain an assessment carried out by a person trained to do so.Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 1 Key findings/Evidence Standard met? The Home conducts a pre-admission assessment. One of three trained nurses will visit a prospective service user in their own home or in hospital before an admission is agreed. The inspector remains very concerned about the manner in which service users are admitted to the Home. Admissions would appear to be arranged around the availability of a place rather than the needs of the individual or the service user group as a whole. It was clear from three service users assessments that there was an expectation by social workers that the service users would be placed within the EMI unit when in fact no places were available. This was confirmed in a returned visiting professional survey, telephone discussion with a professional visitor and in review minutes. Two service users were not being cared for within the Unit and a third was residing outside the unit but using the facility during the daytime hours. All were placed in the area that accommodates service users who are older people with either nursing and or social care needs. The inspector has concerns around the placement of service users in specifically registered areas of the Home particularly around dementia and mental disorder categories and the appropriateness of the mixed needs of those service users. There appears to be confusion in respect of mental disorder or enduring mental health needs and dementia as a condition of old age. Regulation 14 ­ Assessment of service user 14(1) states the registered person shall not provide accommodation to a service user at the care home unless, so far as it is shall have been practicable to do so ­ (d) the registered person has confirmed in writing to the service user that having regard to the assessment the care home is suitable for the purpose of meeting the service users needs in respect of his health and welfare.Ainsworth Nursing HomePage 19 Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? This standard is not applicable to this setting.Ainsworth Nursing HomePage 20 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 3 Key findings/Evidence Standard met? The inspector examined three service user files selected at random. They appeared to be in good order and are reviewed on a monthly basis. Information includes an information sheet, pre-admission assessment, medical records and professional visits, care plan, mobility and manual handling assessment, risk assessments etc.Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) 1 03 Key findings/Evidence Standard met? The inspector examined three service user care files. Care files contained evidence of service users receiving GP, chiropody visits and annual sight tests. Risk assessments regarding nutrition, moving and handling/risk of falls and pressure area/skin integrity were in place. Service users were being weighed monthly. Seated weighing scales are provided.Ainsworth Nursing HomePage 21 Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 2 Key findings/Evidence Standard Met? Policies were seen describing the safe handling of medicines in the home but need expanding to include the use of homely remedies and covert administration. Registered nurses manage and administer all medication in the home. None of the service users look after their own medication, but one service user is being encouraged to apply their own cream. Where the need for covert administration has been assessed this is clearly recorded however, it is recommended that nurses obtain a copy of the Nursing and Midwifery Council Guidance on covert administration for consideration. Medication Records were generally complete and up-to-date, however where medication was given other than in accordance with the labelled instructions, the reason was not clearly referenced, and there was some crossing-out and overwriting in the controlled drugs register. All medication records must be complete, accurate and up-to-date. `Homely Remedies were used but the home does not maintain a separate dedicated stock. The medication storage areas were secure, but some expired, unlabelled, discontinued or otherwise unwanted medication remained in the stock cupboards; One item was in-use beyond the normal 28-day period. The dedicated medication refrigerator temperature was higher than the normal range. Medication with a reduced in-use shelf life must not normally be used for extended periods, unwanted medication must be promptly returned to the pharmacy for destruction and the correct refrigerator temperature must be maintained. Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 2 Key findings/Evidence Standard met? During discreet observation of care practices no concerns were expressed in respect of privacy and dignity. However the inspector did raise concerns about the storage of reuseable medical equipment and appropriateness of present arrangements. The practice of keeping medical equipment that should maintain a high degree of infection control should not be stored on the floor in bedrooms. This is unacceptable and appropriate storage must be obtained.Ainsworth Nursing HomePage 22 Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Ainsworth Nursing HomePage 23 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 2 Key findings/Evidence Standard met? Concerns have been raised at previous inspections about the lack of stimulation afforded to service users. At the last inspection a new person has recently been employed to fill this role but they are currently working as a carer. The registered manager at the time said this was to give the person an opportunity to get to know service users. As stated at the last inspection activities for service users need to be resumed as soon as possible. Manon wing is an EMI unit. Activities are needed to better meet the specialised needs of service users with dementia/confusion. Up to date information about these activities should also be provided i.e. weekly activities programme. The nurse in charge has a number of ideas that could be put in practice to improve orientation and these now need to acted upon. Most service users spent their time in the communal lounges. However some service users spend the majority of their time in their rooms and pursue there own interests such as listening to music, watching television, doing crosswords etc. The inspector observed service users into the early evening and up to bedtime. Service users with nursing needs are assisted to get ready for bed after supper from about 7.30pm onwards. Other service users were seen to request assistance to go to bed. More able service users said that they generally went to their bedrooms after supper to watch TV but they could stay up later if they so wished. Most service users were in their rooms by 8.45pm. Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 3 Key findings/Evidence Standard met? Visitors were observed to be coming and going throughout the day. The inspector spoke to two relatives who were visiting relatives during the course of the inspection. They were visiting at teatime and early evening. Both visitors were complimentary about the care their relative was receiving. One stated that they had looked at a number of Homes before choosing Ainsworth. The decision to place their relative was made on the basis of the homely and welcoming atmosphere.Ainsworth Nursing HomePage 24 Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 2 Key findings/Evidence Standard met? The inspector sampled a dinner with service users at lunchtime. Service users who were able to speak with the inspector said that they enjoyed the meals provided and particularly that they are home cooked. A choice was offered to service users. Discussion with kitchen staff confirmed that they had all the equipment they needed to carry out the task and that they were happy with the quality of the food provided. A record of food serviced to service users must be maintained and retained for one year in accordance with the regulations. It was noted that two of the requirements were still outstanding in relation to the last environmental health food hygiene inspection that took place on 07.06.04. These are that the cupboards under the sinks are replaced and that a portable fridge thermometer is purchased for a freezer.Ainsworth Nursing HomePage 25 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 0 0 0 0 0 4 X 2 Key findings/Evidence Standard met? At the last inspection no internal complaints procedure could be located in a prominent place in the Home for the attention of service users and their families. A complaints procedure was eventually found but it was old and information was out of date. This procedure was amended but more work needs to be done in order for it to comply fully with Regulation 22. Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 2 Key findings/Evidence Standard met? It was discussed at previous inspections that information relating to independent advocacy schemes needs to be made available to service users and there relatives. Some information was found during the course of the inspection and this needs to be placed in a prominent place. The information in some cases was dated and there is a need to confirm addresses and telephone numbers. This situation remains the same.Ainsworth Nursing HomePage 26 Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists NO 01 Key findings/Evidence Standard met? As identified at the last inspection the Homes present abuse procedure only makes reference to sexual and physical abuse and needs to be developed further. The registered manager had obtained a copy of the Local Authority Adult Protection procedure. A copy of No Secrets also needs to be acquired. Staff members require training on Adult Protection, whistle blowing and abuse issues. This requirement has now been outstanding for sometime and now requires urgent attention. Regulation 13 - Further requirements as to health and welfare ­ states (6) ­ The registered person shall make arrangements, by training or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse.Ainsworth Nursing HomePage 27 EnvironmentThe intended outcomes for the following set of standards are: · 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. Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 2 Key findings/Evidence Standard met? Most of the standards relating to the physical environment from previous inspections have now been addressed. However, other issues of concern were evident. The following requirements were made at this inspection. · As at previous inspections bedding was well worn and in need of replacement in some cases. At the last inspection it was noted that bedrooms would be visually improved by a more co-ordinated approach in relation to their refurbishment. The inspector acknowledges some improvement in this area. It is suggested that coordinated bedding be returned and stored in individual service users bedrooms. · The chair in C12A needs to be replaced. · Significant malodour was noted in bedrooms C9 and C14. · The main corridor to Cyrano needs repainting and carpet is intensively cleaned. · Bedrooms C2 C11 and C14 need repainting. · That more armchairs that are washable are purchased for the Home. · That in bedroom C7 a washable surface is put around the walls of the bed to assist with cleaning and a vinyl floor covering put in place of the carpet. · That old and damaged furniture continues to be replaced. · Bedroom M10 needs a new mattress. The inspector raised concerns on the part of the Home at the beginning of this inspection in respect of the lack of action in responding to a recent fire officers report received by the Home on 5th August 2004. The director of the company quickly moved to have a Fire Risk Assessment conducted on behalf of the Home. The Fire Officer visited the premises on 28.09.04 to clarify issues in the fire report with the inspector, a director of the organisation and the handyman. Some of the necessary work had been undertaken by the time of this visit. All outstanding items on the report must now be addressed. This includes that all staff and service users are trained in evacuation procedures and are made aware of changes. Two service users have requested or need the fitment of automatic door release mechanisms (M7&C12) to their bedroom doors and two corridor doors were also identified.Ainsworth Nursing HomePage 28 Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 2 Key findings/Evidence Standard met? Cyrano Wing There are two combined lounge/dining rooms in this area. One for up to six service users and a second for up to twenty service users. A quiet area/lounge/meeting room that was recently created when the old dining room was varied to provide two new bedrooms has recently been turned into a second office for the registered provider and is now locked most of the time. This room must revert back to the intended purpose for the use of service users. Manon Wing This wing has one lounge/dining room for up to 11 service users. A smoking area was provided in the corridor. This area is immediately adjacent to the lounge and a bedroom. Although a nearby external door could be opened in warm weather to provide ventilation, this would not be practical when it was cold. It has been suggested in previous inspection reports that the Home monitors the smoke in this area, with a view to providing a small smoke extractor. Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 2 Key findings/Evidence Standard met? On the EMI unit there is one assisted bath and two communal toilets. Both toilets are very small and make it difficult for staff to provide practical assistance to a service user discreetly, particularly the toilet on the ramp. There appears to be some scope to lengthen the toilet to the ramp area. This matter needs to be addressed. The commode chair currently being used as a shower seat in the walk in shower to the nursing/residential area of the Home is rusting badly and is a hazard to service users. This needs to be replaced with a shower chair fit for the purpose. Storage for incontinence aids, gloves, towels etc is also needed in this shower room. Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 2 Key findings/Evidence Standard met? This standard was not fully assessed at this inspection. However the inspector did express concern at the appropriateness of a chair being used for a service user in terms of safety, comfort and potential pressure. This matter needs to be addressed by an appropriate professional as soon as possible.Ainsworth Nursing HomePage 29 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite NO YES NO 29 2 4 0 29XX X 4 X2 Key findings/Evidence Standard met? At a meeting held on 01.09.03 with the registered provider and the director of the company it was agreed that the number of places at Ainsworth would be reduced to 37 service users. There were four double rooms identified M8, C10, C12 and C16. It must be noted that none of these rooms were being used as double rooms at the time of this agreement and they had been contracted with the current service users as single rooms. It was the expectation of the NCSC at the time that these arrangements would be honoured and that they would only revert to double rooms once they became free.Ainsworth Nursing HomePage 30 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 2 Key findings/Evidence Standard met? Bedrooms in general appeared to meet the standards for Homes registered prior to the Care Standards Act. A number of items of furniture were found to be in a poor condition and need to be repaired or replaced. The replacement of windows needs to be extended to all bedrooms on Cyrano particularly those to the rear of the Home that are in poor condition, ill fitting and a security problem in some cases. Further to a visit by an inspector from HSE on 08.09.04 an improvement notice was issued in respect of window restrictors being placed in first floor bedrooms. An improvement notice was served. Some bedding would benefit from being replaced. Each bedroom had a wash hand basin and a door lock. Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Ainsworth Nursing HomePage 31 Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 1 Key findings/Evidence Standard met? As identified at previous inspections, there are significant concerns about the present laundry arrangements. Laundry facilities on Manon wing are housed internally. However on Cyrano wing the laundry is located away from the main building in an out building that is storing lots of other items, set in an isolated position up a small rise with no heating or running hot water. Laundry staff ferry washing to and from this laundry via a washing basket on a wheelchair. The inspector feels that this situation presents a number of health and safety issues including moving and handling, staff members security and control of infection. The laundry assistants have nowhere appropriate to hang and fold washing or to iron. The current laundry arrangements are considered to be woefully inadequate in a 21st century nursing home. The inspector contacted HSE who are responsible for health and safety matter in nursing homes to review this situation. The HSE inspectors findings include the following requirements. · That adequate ventilation is available in the internal laundry. · That the external laundry is heated to a temperature of 16 degrees Celsius during working hours. · That sufficient space is available for sorting, folding and ironing of clothes. · Suitable trolleys should be provided for the collection and movement of linen. · That the paved area is improved so that it is level and free from trip hazards. · Consideration should be given to raising the washing machines and dryers from floor level so the doors are more easily accessible. Also required by CSCI: · The electrics in the external laundry meet NICEIC standards and that this is validated. · That the fire officers recommendations are met in respect of the laundry. The HSE inspector also raised concerns in respect of clinical waste procedures at the Home. The following requirements were made. · That clinical is stored in identifiable lockable bins whilst waiting for disposal. · That all staff members handling clinical waste are provided with disposable gloves and aprons. · That all staff members including domestics receive control of infection training and that this is evidenced. Also required by CSCI: · That the practice of leaving both the laundry trolley and clinical waste at the back door lobby cease as this is a means of escape. At the beginning of the inspection the Home had been down one domestic for approximately three months. The CSCI inspector noted deterioration in the standard of cleanliness at this point in the inspection. The following requirement is made. · That adequate domestic staffing levels are provided at the Home at all times.Ainsworth Nursing HomePage 32 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours 22 X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff 10 2 X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X X3 12 82 Key findings/Evidence Standard met? The above figures for service users level of need are based on those provided by the registered manager at the time, on the Pre Inspection Questionnaire. Due to the death of the registered matron/manager the Home was operating with only three fulltime nurses who were working overtime to meet the needs of the Home. This situation is a temporary arrangement that cannot be maintained for long. See Standard 31. Given the clear distinction set between the three areas of service provided, a review of the present staffing arrangements is now required to ensure that all service users needs can be met and that continuity of care is provided.Ainsworth Nursing HomePage 33 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 Key findings/Evidence This standard was not assessed at this inspection. X X Standard met? 0Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 1 Key findings/Evidence Standard met? At the last inspection the files of the last two staff to be employed by the Home and a number of existing employees were examined. A number of issues were raised and some have been dealt with. The following remain outstanding. · Copies of any training certificates or professional qualifications must be kept. · The format of the Homes application form still needs to be amended as it only asks for details of one job, with no start or leave dates requested. In order for the manager to fulfil her legal duty to fully explore an applicants work history with regard to gaps, contacting last employer, previous relevant experience, the home was advised to redesign the form, with space for current or most recent job, plus space for previous jobs and start and leave dates as specified in Standard 29.1. The inspector is aware that since the last inspection the registered manager has been taking details of employment history. However close inspection of one identified discrepancies and they are separate from the declaration on the application form. · The inspection identified concerns about the quality of some references. A reference must be taken from the employees past employer and not an ex-colleague. Regulation 19 - Fitness of workers ­ (1) ­ states the registered person shall not employ a person to work at the care home unless ­ (a) ­ the person is fit to work in a care home ­ (b) ­ subject to paragraph (6), he has obtained in respect of this person the information and documents specified in ­ (i) paragraphs 1 to 7 of Schedule 2; (c) ­ he is satisfied on reasonable grounds as to the authenticity of the references referred to in paragraph 5 of Schedule 2 in respect of that person.Ainsworth Nursing HomePage 34 Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 1 Key findings/Evidence Standard met? There is a comprehensive induction booklet for new starters. Discussion with a new member of staff confirmed that they were paired up with an experienced member of the staff team when they commence employment but that no formal induction process was completed. At previous inspections the inspector has required that a thorough induction programme for new staff be developed which is recorded. This has yet to be done. At the last inspection some existing staff had received moving & handling and fire safety training. The registered manager at that time said that all staff had now completed the training but was unable to confirm the dates. Individual training record sheets are kept but more detail about the length of any training attended is needed and a more organised approach to filing information is also needed. This remains the case at this inspection.Ainsworth Nursing HomePage 35 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 1 Key findings/Evidence Standard met? As stated in the summary the registered manager became ill during the course of the inspection and later sadly died. The registered manager was qualified as an RGN and RM and had been in matron/manager of Ainsworth since 1988. The registered matron/manager had dedicated her working life to nursing. On the 17.09.04 the inspector met with the registered provider and her husband, a director of the company, to pass on her commiserations. It was also discussed that given the ongoing issues that had been evident for some time that there was an urgent need to appoint a new matron/manager as soon as possible. The necessary competencies of the new registered manager were discussed. Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Ainsworth Nursing HomePage 36 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 1 Key findings/Evidence Standard met? The following matters were identified at the previous inspections. The inspector met with the registered provider and her husband on 17.09.04. The registered provider confirmed that Ainsworth Nursing Home is a company and that her husband is a director of that company. Ongoing concerns in respect of the quality of care of the Home provided were discussed. There is a need to review the quality of care provided. The registered provider in line with Regulation 24 must conduct the review. Although the registered provider visits the Home regularly this is usually to deal with financial arrangements only. The inspector also requires the registered provider to, in line with Regulation 26, conduct unannounced monthly visits. A written report of the visits shall be provided to the Commission. The registered provider was given a copy of the CSCI format by the inspector to assist in the report writing for this task. Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Ainsworth Nursing HomePage 37 Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders Key findings/Evidence This standard was not assessed at this inspection. Standard met? 0 X X XStandard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 2 Key findings/Evidence Standard met? As identified at the last inspection, a formal staff supervision system needs to be put in place that meets with Standard 36. This matter remains outstanding. Regulation 18 ­ Staffing - (2) states the registered person shall ensure that the persons working at the care home are appropriately supervised.Ainsworth Nursing HomePage 38 Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 2 Key findings/Evidence Standard met? There are ongoing concerns about the efficiency of the present administrative arrangements. Since the last inspection the Home has purchased a computer and a fax machine. The inspector is aware that the registered provider has advertised for an administrator, however as yet no one has taken up the post. Confidential information is not securely held. A full assessment of the Homes policies and procedures is needed. Regulation 17 ­ Records ­ (2) states the registered person shall maintain in the care home the records specified in Schedule 4. (3) The registered person shall ensure that the records referred to in paragraphs (1) and (2) ­ (a) are kept up to date; and (b) are at all times available for inspection in the care home by any person authorised by the Commission to enter and inspect the care home. Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 0 Key findings/Evidence Standard met? This standard was not fully assessed at this inspection. Please refer to other Standards in this report in respect of issues relating to health and safety.Ainsworth Nursing HomePage 39 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition Compliance Within the maximum registered number Service users to include up to 41, there can be up to 20 MD (Mental Disorder), up to 20 OP (Older People) and up to 2 PD (Physical Disability) CommentsCondition Compliance The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection CommentsCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateJulie Bodell Ian Jeavons 2 November 2004Signature Signature SignatureAinsworth Nursing HomePage 40 Public reports It should be noted that all CSCI inspection reports are public documents.Ainsworth Nursing HomePage 41 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 6/8/17/28 September and 7 October 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possible We are working on the best way to include provider responses in the published report. In the meantime responses received are available on request.Ainsworth Nursing HomePage 42 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONOYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. Please provide the Commission with a written Action Plan by 30 November 2004, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YES D.2Action plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planNOYESOther: enter details here Ainsworth Nursing HomePage 43 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Ainsworth Nursing HomePage 44 Ainsworth Nursing Home / 6th 8th 17th & 28th September 2004 7th October 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000017312.V171686.R01© This report may only be used in its entirety. 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