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Inspection on 08/03/06 for Ainsworth Nursing Home

Also see our care home review for Ainsworth Nursing Home for more information

This inspection was carried out on 8th March 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Ainsworth has a stable staff team and a good rapport was noted between them and the service users. Service users said that they felt the staff team was caring and that nothing was too much trouble.

What has improved since the last inspection?

Ainsworth has in recent years been subject to a significant number of requirements over the last few years, with very slow progress being made. The Home appointed a new registered manager last year and the inspector is pleased to report that given the short period of time that the manager has been in post significant progress has been made in addressing issues, many of which have been outstanding for sometime. There is however more to do. The registered provider has ensured that the registered manager has had the time available to continue to make the required improvements at Ainsworth and to allow time to ensure the effective day-to-day management of the Home. The Home is now only admitting service users that they have the necessary skills and experience to care for. Service users spoken with were highly complimentary about the new manager who they said was very approachable and understanding of their needs and that they felt more comfortable raising issues of concern and that "she always had a smile for them." Service users had noticed many improvements at the Home. Conversations with members of the staff team gave a similar response and care staff felt that they were being valued more and were pleased that they had been trusted to be involved in the new key worker system. Night staff members too have been involved in this process and are included more. Training is scheduled at a time that enables them to attend. A suitably qualified electrician has undertaken work to ensure the Homes electrical fittings and fixtures are safe. Issues surrounding control of infection in respect of training, cleaning products and the laundry have been addressed. The provision of food has been reviewed to ensure that service users are receiving good quality, wholesome food that offers choice. The findings of that review now need to be addressed. Improvements have been made to the medication system.

What the care home could do better:

The outstanding work identified by the fire officer must be completed. Improvements are needed to the arrangements in the kitchen and the quality of the food that is provided. The registered providers and the registered manager need to work closely together to avoid unnecessary delays in responding to health and safety requirements. All the staff team and the registered providers must attend adult protection training. The registered provider must visit the Home on a monthly basis and look at the quality of care provided and address any issues. Work to improve the physical standards at the Home need to continue. The specialist chair needed by a service user must be purchased.

CARE HOMES FOR OLDER PEOPLE Ainsworth Nursing Home Knowsley Road Ainsworth Nr Bolton Lancashire BL2 5PT Lead Inspector Julie Bodell Unannounced Inspection 8th March 2006 07:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ainsworth Nursing Home DS0000017312.V257686.R01.S.doc Version 5.1 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.V257686.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ainsworth Nursing Home Address Knowsley Road Ainsworth Nr Bolton Lancashire BL2 5PT 0161 797 4175 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) Mrs Pooganthai Subbiah Tina Jacqueline Harrison 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.V257686.R01.S.doc Version 5.1 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). 15th July 2005 2. 3. 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. Ainsworth Nursing Home DS0000017312.V257686.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and took place at 7.00am – 3pm. The inspector spent time interviewing the registered manager, three staff members including night staff, three service users, looking around the building and at key information. Since the last inspection in June 2005, three additional visits have been made, on 5th October 2005, 17th November 2005 and 27th January 2006 to check that progress on outstanding requirements and that improvements in service delivery were being undertaken. Many outstanding requirements have been met. What the service does well: What has improved since the last inspection? Ainsworth has in recent years been subject to a significant number of requirements over the last few years, with very slow progress being made. The Home appointed a new registered manager last year and the inspector is pleased to report that given the short period of time that the manager has been in post significant progress has been made in addressing issues, many of which have been outstanding for sometime. There is however more to do. The registered provider has ensured that the registered manager has had the time available to continue to make the required improvements at Ainsworth and to allow time to ensure the effective day-to-day management of the Home. The Home is now only admitting service users that they have the necessary skills and experience to care for. Service users spoken with were highly complimentary about the new manager who they said was very approachable and understanding of their needs and that they felt more comfortable raising issues of concern and that “she always had a smile for them.” Service users had noticed many improvements at the Home. Conversations with members of the staff team gave a similar response and care staff felt that Ainsworth Nursing Home DS0000017312.V257686.R01.S.doc Version 5.1 Page 6 they were being valued more and were pleased that they had been trusted to be involved in the new key worker system. Night staff members too have been involved in this process and are included more. Training is scheduled at a time that enables them to attend. A suitably qualified electrician has undertaken work to ensure the Homes electrical fittings and fixtures are safe. Issues surrounding control of infection in respect of training, cleaning products and the laundry have been addressed. The provision of food has been reviewed to ensure that service users are receiving good quality, wholesome food that offers choice. The findings of that review now need to be addressed. Improvements have been made to the medication system. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ainsworth Nursing Home DS0000017312.V257686.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ainsworth Nursing Home DS0000017312.V257686.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 The registered manager is clear about her responsibility that appropriate assessments must be undertaken before service users’ moved into Ainsworth to ensure that their needs can be fully met by the staff team. The statement of purpose and function must now be amended to reflect the new certificate. EVIDENCE: Following the last inspection the certificate for the Home was amended and a new certificate issued to accurately reflect the numbers and categories of service users at the Home in a way that will identify three discreet specialist areas within the Home. The registered manager who had inherited this situation is aware of her responsibilities and is adhering to the agreed arrangement. This has been difficult to achieve at this time because people are mixed throughout the building and a number of service users are reluctant to move. The inspector is now confident that over a period of time this will be achieved over time. The statement of purpose and service user guide has been reviewed and revised to reflect the conditions and this work is close to completion. Ainsworth Nursing Home DS0000017312.V257686.R01.S.doc Version 5.1 Page 9 A sample of care records for three service users’ confirmed that an assessment by either a social worker, community psychiatric nurse or a general nurse is carried out prior to a service user being admitted to Ainsworth. Issues around one community care assessment were discussed and this links to the service user’s a risk assessment for the Home, which differs. The manager is fully aware of the situation and the matter is being dealt with. Ainsworth Nursing Home DS0000017312.V257686.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 79 Care plans and risk assessments examined were seen to be in good order. Improvements have been made to the medication system, which helps to protect the service users by ensuring safer practices. EVIDENCE: The registered manager has not made any changes to the original care plan or assessment formats. Three service users care plans and risk assessments were examined. Care plans seen were in good order and up to date. The inspector was pleased to see a service user who initially was nursed in bed now up and able to sit with other service users in the lounge. The medication is in the process of being upgraded. Two new medication trolleys that are able to house blister packed medication have been purchased. Training is arranged and the new system is due to become operational on 27th March 2006. Ainsworth Nursing Home DS0000017312.V257686.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 15 Now that the review of the provision of food has been completed the findings must be implemented and include the issues identified in this report. EVIDENCE: The inspector arrived for this inspection at 7.00am. It was noted that most service users were still in bed and were staff members said that they were under no pressure to get service users up. The pace was very relaxed. Breakfast was served at 9.20am. Mugs of tea were served from a large teapot. The tea was lukewarm. Porridge was served and a choice of cornflakes and Weetabix with hot or cold milk, followed by toast and marmalade. Staff members wore the appropriate aprons to serve food. The arrangements for eating meals are poor, with only one large table with an array of odd chairs available to service users. A new dining room table and chairs is needed for the top lounge/dining room. Service users who needed assistance with feeding received appropriate support and were served first. At the last inspection it was found that although the cook was held in high regard, some service users said that they were not always happy with the food they received and that they would like better quality food including the tea and said that they would like brown bread to be offered with meals. Since then the Ainsworth Nursing Home DS0000017312.V257686.R01.S.doc Version 5.1 Page 12 registered manager has reviewed the menu to ensure that a varied, wholesome and a balanced diet is provided and that choice is available to service users. This menu has yet to be implemented. The inspector spent time looking at the kitchen and a number of concerns were raised including the need to clean shelves in the dry food store and fridges, bread purchased by the provider was not in trays, had been left on a dirty floor and then was to be put into freezers, a number of out of date tins, food frozen that according to the label should not have been, mouldy fruit and tomatoes and lids were not closed on some dried goods which could result in contamination. Added to this kitchen staff were not wearing head protects and the kitchen was not locked and left unsupervised at break time, which service users could access, with pans left boiling on the stove. This is unacceptable. Ainsworth Nursing Home DS0000017312.V257686.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 18 Given recent events at Ainsworth further improvements are required by the registered provider to ensure that the staff team receive good quality adult protection training and this must include the registered providers. The responsible individual must ensure that she complies with POVA legislation. EVIDENCE: There is a complaints procedure in place. There has been one internal complaint, which has been appropriately dealt with and documented. There have been no complaints investigations conducted by the CSCI since the last inspection. The registered manager is updating adult abuse training. There was a training session held for the staff team at the end of January 2005. This training was undertaken prior to the present manager taking up post. The training was not certificated and was poorly attended. The registered manager is unhappy with the quality of this training and is planning to access local authority training for the staff team. This matter must be addressed as soon as possible. There was a serious incident at the Home last year. The provider has notified both POVA and the NMC/UKCC about the incident and this has been confirmed. However further information requested by the POVA team and CSCI has yet to be received from the registered provider as requested at an additional visit that took place on 27th January 2006. Ainsworth Nursing Home DS0000017312.V257686.R01.S.doc Version 5.1 Page 14 Relating to the same incident, it was agreed that the registered provider would write a report giving details of contact with the placing authority in respect of lack of social worker input that relates to a small number of identified service users (this includes none payment of fees). Also discussed was the responsibility of the registered provider to produce risk assessments for any person with a criminal conviction and whether they pose a risk to service users. Information requested on how this will be achieved has yet to be received. Ainsworth Nursing Home DS0000017312.V257686.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 21 22 26 The physical standards at Ainsworth are steadily improving for service users’. there. However, there are serious concerns about the delay in the registered provider addressing health and safety matters, which could have an impact on the health, safety and comfort of service users. EVIDENCE: An immediate requirement was served at the last inspection in respect of the electrical fittings and fitments throughout the Home. This work has know been completed. At an additional visit that was undertaken 27th January 2006. A fire officer visited with a colleague to ensure that all the work required at his last visit had been undertaken. Although the registered provider was aware of the situation and a number of contractors had been on site and assessed the work required, there was a shortfall and this resulted in an enforcement notice being issued. Ainsworth Nursing Home DS0000017312.V257686.R01.S.doc Version 5.1 Page 16 This is not the first time that a health and safety enforcement notice has been served against the registered provider who despite being aware of the problem takes a long time to carry out the work. The inspector is also aware that enforcement action is pending in respect of the Homes septic tank from the environment agency. Most of the standards relating to the internal physical environment from previous inspections have now been addressed. It is noted that bedrooms have started to improve due to a more co-ordinated approach in relation to decoration and furnishings. Some bedding was checked at this inspection and was observed to be very thin and more slide sheets are needed. Old and damaged furniture continues to be replaced and this situation will continue to be monitored at future inspections. One service users bedroom was identified as needing decorating. Locks have been removed to four doors and now must be fitted with appropriate locks. Carpets along the main corridor are fitted in such a way that they are lifting in parts and could present as a trip hazard. The main corridor needs to be decorated. The paint and paper have been purchased to carry out this work. Since the last inspection the shower seat in the walk in shower to the nursing/residential area of the Home has been replaced with a chair that is robust with arms to prevent service users from falling and leave them feeling less vulnerable. The shower room has been upgraded and storage is in place for incontinence aids, gloves, towels etc. Service users have the specialist equipment they need. However, at previous inspections the inspector has requested that an appropriate professional look at the situation in respect of the bucket type chair being used for a service user, in terms of safety, comfort and potential pressure again. This has been done and an alternative has been identified. It is now available and is waiting to be purchased by the registered provider. The Home and the standard of hygiene and cleanliness within Ainsworth continue to improve. Training for staff members has now been arranged in control of infection. New products for cleaning have been introduced into the Home. Ainsworth Nursing Home DS0000017312.V257686.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 Adequate staffing was available to service users to ensure that their needs could be met. EVIDENCE: On arrival at the Home there were four members of the night staff on duty. One member of staff had worked at the Home for four years and three new members of who had worked at the Home for four months including one qualified nurse. One staff member confirmed that they had received fire safety training, moving and handling and control of infection training. The staff member was aware that if they had concerns about another staff member’s practice that they would speak to their immediate line manager and/or the registered manager. The new staff members’ said that the Home had been welcoming and the team was very supportive. The cook was in the kitchen preparing breakfast. Three nurse and four carers arrived on duty just before 8am and received a handover that included every service user, from the nurse going off duty. A work sheet was available to the staff team to ensure that they had clear instruction of what duties they had been assigned to that day. An updated moving and handling training session was arranged for that evening between 6pm –9.30pm so that night staff members could attend. Ainsworth Nursing Home DS0000017312.V257686.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 32 33 34 38 The registered manager is fully aware of her role to promote and safeguard the health, safety and welfare of the service users. However the registered provider continues to be slow to respond to requirements made by various statutory agencies and has not always kept the registered manager informed. This is to the detriment of service users and the running of the home. The registered providers’ and the registered manager must work together if the present progress achieved is to continue. EVIDENCE: The registered manager is a qualified nurse with many years experience of both working and managing residential homes for older people. It has been clear through discussion with both service users and members of the staff team that the registered manager has made an immediate impact in improving the service offered at Ainsworth, in terms of decision making, communication, increasing the responsibility of the staff team, improving relationships with outside agencies, increasing the opportunities for activities for service users Ainsworth Nursing Home DS0000017312.V257686.R01.S.doc Version 5.1 Page 19 and training opportunities for the staff team. The registered manager was said to be approachable and always had a ready smile. The registered manager is however under no illusion that there is much more to do in terms of modernising the Home. The inspector is very pleased to see the progress that has been made by the registered manager, who has been in post now for nearly a year, as the standards that have been presented at previous inspections were unacceptable and that situation would not have been allowed to continue for much longer without further action being taken by the CSCI. The Home would benefit from computer access for word processing, email and Internet, as well as administrative support. As stated at previous inspections the relationship between the registered manager and the owners of Ainsworth is key to ensure continued improvements and progress towards a better future for all concerned. Since the last inspection there has been some improvement in that relationship but yet again situations have arisen that have led to enforcement action on the part of statutory organisations that could have been avoided. This is unacceptable and undermines the improvements made by the registered manager and the staff team. As at previous inspections that at these times a director of the company rather than the responsible individual appears to be taking responsibility for addressing matters. The Home is registered, as Ainsworth Nursing Home Ltd with Company House and this is not reflected on the Home’s certificate. The inspector will be conducting an additional visit to discuss this matter with the owners and to review the financial arrangements for the Home including account systems. As required at previous inspections the responsible individual in line with Regulation 24 must conduct a review of the quality of care. This process has already started to be addressed by the registered manager. The inspector also required the registered provider to, in line with Regulation 26, conduct unannounced monthly visits. A written report of the visits should be forwarded 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 and has been supported by the registered manager to do so. Again only one has been received since the last inspection. Regulation 26 visits are a good way of identifying and addressing problems that arise, as well as formally addressing issues raised in the monthly managers report, so they do not escalate into enforcement action. A gas service was being undertaken on the day of the inspection. It was clear from the engineer that changes to the contract had been made. This matter needs to be addressed to ensure that all the necessary checks have been undertaken to an annual timescale. Ainsworth Nursing Home DS0000017312.V257686.R01.S.doc Version 5.1 Page 20 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 2 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 1 X 2 1 X X X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 2 X X X 2 Ainsworth Nursing Home DS0000017312.V257686.R01.S.doc Version 5.1 Page 21 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 OP1 Regulation 6 Requirement That the statement of purpose and service user guide is reviewed and revised and a copy sent to CSCI. (Outstanding) That the issues identified in the body of this report are addressed. (Ongoing) That all staff members receive appropriate adult protection training. That all the copies of documentation requested by the inspector are forwarded to CSCI. (Ongoing) That where necessary bedding (including slide sheets) and furniture are replaced as identified in the body of this report. (Ongoing) That the outstanding requirements of the Fire Officer are addressed. That the suitable chair identified for a named service user is purchased. (Ongoing) That the registered provider visits the Home unannounced on a monthly basis in accordance with the Regulation. Outstanding DS0000017312.V257686.R01.S.doc Timescale for action 30/04/06 2. 3. 4. OP15 OP18 OP18 16 13 37 30/04/06 31/05/06 30/04/06 5. OP18 16 30/06/06 6. 7. 8. OP19 OP22 OP33 23 13 26 30/04/06 30/04/06 30/04/06 Ainsworth Nursing Home Version 5.1 Page 22 9. 10. OP34 OP38 25 31 That the accounts for the organisation are available for CSCI to view. That a copy of the Homes gas safety certificate is forwarded to CSCI. 31/05/06 30/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ainsworth Nursing Home DS0000017312.V257686.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ainsworth Nursing Home DS0000017312.V257686.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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