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Inspection on 25/07/06 for Aldergrove Manor Nursing Home

Also see our care home review for Aldergrove Manor Nursing Home for more information

This inspection was carried out on 25th July 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

The home provides a clean and comfortable environment where residents are cared for by appropriately skilled staff. Regular training opportunities are provided by the home, which ensures that staff are kept up to date with current good practice. Care planning remains clear and effective and the home continues to monitor and review processes to ensure residents receive a good range of quality services. The home is divided into three main areas, which enables individuals with a range of conditions to reside at the home and be cared for by specific staff groups.

What has improved since the last inspection?

A recommendation that was made at the inspection in March 2006 was to introduce systems to increase resident consultation and involvement in the day to day running of the YPD Unit. The home has initiated monthly meetings with residents on this unit, and most individuals commented that they were satisfied with their current "input" into the running of the unit

What the care home could do better:

The inspection identified that shortfalls within the home are few. The home is required to introduce systems to reduce the temperatures of all medication storage rooms within the home and to ensure that staff are fully aware of the required temperature range for the drugs fridges. From observations made of care files for residents accommodated on the nursing unit, it is recommended that staff record more information to demonstrate the nursing input in a residents care.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Aldergrove Manor Nursing Home 280a Penn Road Penn Wolverhampton West Midlands WV4 4AD Lead Inspector Rosalind Dennis Key Unannounced Inspection 25th July 2006 10.00 X10029.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Aldergrove Manor Nursing Home DS0000017175.V306876.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People and Care Homes for Adults 18 – 65*. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Aldergrove Manor Nursing Home DS0000017175.V306876.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Aldergrove Manor Nursing Home Address 280a Penn Road Penn Wolverhampton West Midlands WV4 4AD 01902 621840 01902 621841 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) www.schealthcare.co.uk Southern Cross Healthcare Services Limited Mrs Debbie Rowley Care Home 70 Category(ies) of Dementia - over 65 years of age (19), Old age, registration, with number not falling within any other category (27), of places Physical disability (17), Terminally ill (7) Aldergrove Manor Nursing Home DS0000017175.V306876.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home may accomodate up to 34 elderly persons requiring nursing care of which upto 7 persons may require palliative care. Ground Floor Nursing/Palliative Care Unit (34 beds) Unit Manager with 10 supernumerary hours per week Service Users 21-25 26-30 31-34 08:00-14:00 1 RGN 4 CA 2 RGN 4 CA 2 RGN 5 CA 14:00-20:00 1 RGN 3 CA 1 RGN 4 CA 2 RGN 4 CA 20:00-08:00 1 RGN 1 CA 1 RGN 2 CA 1 RGN 3 CA First Floor Residential EMI Unit (19 beds) Residential Supervisor with 6 hours supernumerary per week Service Users 1-9 10-12 13-15 16-19 Date of last inspection 08:00-14:00 1 Senior CA 1 CA 1 Senior CA 1 CA 1 Senior CA 2 CA 1 Senior CA 3 CA 14:00-20:00 1 Senior CA 1 CA 1 Senior CA 1 CA 1 Senior CA 2 CA 1 Senior CA 3 CA 20:00-08:00 1 Senior CA 1 Senior CA 1 CA 1 Senior CA 1 CA 1 Senior CA 1 CA 14th March 2006 Brief Description of the Service: Aldergrove Manor is owned and managed by Southern Cross Healthcare Ltd. The manager is Mrs Debbie Rowley. It is a purpose built, two storey building, standing in it’s own grounds and is situated on the outskirts of the city of Wolverhampton. The home is set back off the main road on one of the main routes into Aldergrove Manor Nursing Home DS0000017175.V306876.R01.S.doc Version 5.2 Page 5 Wolverhampton. It is on a main bus route, close to the cities railway system and within easy access to local shops and community facilities. All 71 bedrooms are single with en-suite, some of which have interconnecting doors for couples. Since the inspection in January 2005 the structure within the home has changed and the home now consists of a 19 bedded unit for older people with dementia, a 17 bedded unit for younger adults that have physical disabilities and a 34 bedded nursing unit which includes allocation of 7 beds for palliative care. The range of fees charged by the home varies according to the needs of the individual and whether nursing care is provided. Aldergrove Manor Nursing Home DS0000017175.V306876.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection to Aldergrove Manor lasted approximately seven hours and all ‘key’ National Minimum Standards were assessed during this time. The inspection involved speaking with residents, staff and visitors, observation of a random selection of resident’s bedrooms, looking at care records and observation of documents. The Manager and staff on duty were welcoming and helpful throughout the inspection. Residents appeared well cared for and the staff were observed to attend to residents needs promptly and appropriately. This inspection focussed on the nursing unit and the unit for young physically disabled adults (YPD), an inspection of the dementia care unit had been undertaken in March 2006. What the service does well: What has improved since the last inspection? A recommendation that was made at the inspection in March 2006 was to introduce systems to increase resident consultation and involvement in the day to day running of the YPD Unit. The home has initiated monthly meetings with residents on this unit, and most individuals commented that they were satisfied with their current “input” into the running of the unit. Aldergrove Manor Nursing Home DS0000017175.V306876.R01.S.doc Version 5.2 Page 7 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. Aldergrove Manor Nursing Home DS0000017175.V306876.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Aldergrove Manor Nursing Home DS0000017175.V306876.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory admissions procedure that provides for an effective needs assessment for each resident. EVIDENCE: Observation of a random selection of care files demonstrates that resident’s care needs are appropriately assessed prior to and on admission to the home, pre-admission assessments are completed by the manager or other senior member of staff. In addition to the initial assessment, risk assessments are also conducted and these were present on all files seen for example; nutrition, pressure sore risk, falls risk, moving and handling and risk management plans Aldergrove Manor Nursing Home DS0000017175.V306876.R01.S.doc Version 5.2 Page 10 for residents that are assessed as needing bed rails. Case tracking of these files showed that the needs identified during the assessment process form the basis of care plans and these were found to be individually relevant to each resident. Aldergrove Manor Nursing Home DS0000017175.V306876.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service Users, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is clear and consistent care planning in place, which provides staff with the information they require to meet residents’ needs. Evidence of regular review and good multidisciplinary working ensures that the health and personal needs of residents are met. The administration of medication is generally good, however the storage of medication is not satisfactory and this could impact on the effectiveness of the drugs and put service users at risk. Aldergrove Manor Nursing Home DS0000017175.V306876.R01.S.doc Version 5.2 Page 12 EVIDENCE: A total of five care files inspected contained an extensive range of care plans relevant for each individual case tracked during the inspection. Short term and long term care plans detailed action that is required to address the residents identified problem, any improvements and all showed evidence of regular review. A good range of risk assessments were present in the files seen and on the YPD Unit evidence was available to show that individuals are supported to take risks as part of an independent lifestyle. On the YPD Unit daily entries made by staff into residents care records describe the actual care given and this corresponded to the residents care plan. On the nursing unit entries made on a daily basis into the residents care records provided limited information to describe the care that had been given that day, phrases such as “appears comfortable” were recorded on a regular basis. Although it is acknowledged that files kept in residents rooms provide information in respect of hygiene care, food/fluid intake, frequency of pressure area relief, the home is advised to provide more information in the actual daily record to demonstrate the nursing input in a residents care. Two visitors to the nursing unit described how fluid charts are not consistently completed by staff and an example was shown and discussed with the inspector. It was seen that there was a significant gap in the recording of the fluid intake for this resident for one day and this was brought to the attention of the manager for action. Records to confirm staff contact with and visits by healthcare professionals were well maintained. Sufficient staff working within the home have a recognised palliative care qualification to provide end of life care and additional specialist support and guidance is provided by community hospice staff as required. Residents that were spoken with confirmed that their privacy is maintained. The medication rooms on both the Nursing Unit and YPD Unit were observed to be well organised and Medication Administration Record (MAR) sheets were observed to be complete. Comprehensive medication audits are undertaken for each of the three units and to ensure non-bias a staff member that works on a different unit will complete the audit. Observation of theses audits shows that it has been identified that air-cooling systems are needed in the medication room on the dementia care unit and this is noted in the March 2006 inspection report. On the day of this inspection the temperature of the medication rooms on the nursing and YPD Unit were also found to be excessive, records on the YPD unit show that the temperature has consistently exceeded 25 °C; fitting of air cooling systems on all 3 units must be viewed as a matter of priority. Minimum and maximum temperatures are taken of the drugs fridges, however it was brought to the attention of the manager that the temperature of the Aldergrove Manor Nursing Home DS0000017175.V306876.R01.S.doc Version 5.2 Page 13 drugs fridge on the Nursing Unit had at times exceeded the required range, but there was nothing documented to indicate what had been done about this. Observations showed that Sharps boxes are dated and signed at time of assembly, which is good practice and oxygen is stored appropriately. Risk assessments are in place for individuals that choose to self–administer medication such as inhalers. Aldergrove Manor Nursing Home DS0000017175.V306876.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service Users have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a range of social and recreational activities and the meals at Aldergrove Manor offer choice, variety and cater for different nutritional needs. EVIDENCE: The home has two “activity co-ordinators” and a range of activities is provided for residents to take part in if they choose. Records are maintained of attendance at activities. Aldergrove Manor Nursing Home DS0000017175.V306876.R01.S.doc Version 5.2 Page 15 Residents that were spoken with on the nursing floor spoke positively of the rapport they have with the activities person and felt that there was sufficient and varied activities available. The majority of the residents that were spoken with on the YPD Unit commented that they were happy with how they spend their day, although two residents did comment that there was little to do and described themselves as “bored”; this was brought to the managers attention. The inspection in March 2006 recommended that systems be put in place to increase resident consultation and involvement in the day to day running of the YPD Unit, since this inspection the home has initiated monthly residents meetings and residents commented that they found the first of these meetings useful. Future inspections will monitor whether the home has developed further systems to enhance resident involvement in the day to day running of this unit. Most of the residents spoken with were satisfied with their current “input” into the running of the unit. The Dementia Care unit continues to provide a variety of activities, which are suitable for the needs and capabilities of residents. Observation of menus demonstrates that a varied and satisfactory diet is offered, and that residents are able to request alternatives to the daily menu if they dislike what has been offered. Discussions with the catering team confirmed that apart from the regular menu, they also prepare meals for several people on sugar free diets, and for individuals with swallowing or chewing challenges. Menu plans seen evidence that the home provides diets that also meet the cultural needs of residents. Staff were observed to be attentive in assisting residents to eat and residents that were able to speak with the inspector commented positively on the meals and choices offered. The main home kitchen was not seen, however observation of a recent environmental health officer report shows that the home adheres to required food hygiene standards. Observation of documents regarding a recent incident that occurred at the home demonstrates that the manager seeks appropriate advice prior to imposing restrictions on visiting. Aldergrove Manor Nursing Home DS0000017175.V306876.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service Users feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system that ensures that residents and relatives concerns are listened to and acted upon. The arrangements for the protection of residents from abuse is satisfactory. EVIDENCE: The manager and deputy manager have demonstrated that they have a good knowledge of adult protection processes and procedures and evidence was available to demonstrate that staff have attended adult protection training. Senior staff are due to attend adult protection training provided by the local authority, which should further enhance awareness. A copy of the complaints procedure is available within the Reception area of the home and residents and relatives that were spoken with during the inspection reported that they would notify the manager or deputy manager if they were unhappy with any aspect of their care. Observation of the complaints log showed that the home has not received any recent complaints. Aldergrove Manor Nursing Home DS0000017175.V306876.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment is good providing residents with an attractive, clean and homely place to live. EVIDENCE: A random selection of individual bedrooms and communal rooms were observed to be clean and without unpleasant odour. Discussions with staff Aldergrove Manor Nursing Home DS0000017175.V306876.R01.S.doc Version 5.2 Page 18 confirmed their awareness of the importance of day-to-day routines to promote good standards of infection control and observations made during the inspection confirmed that systems are in place to control the spread of infection. Staff were observed utilising appropriate protective clothing when necessary. Individuals are able to have a key to their rooms if they so wish, although the manager informed that at present no one has requested this facility. Two residents on the YPD Unit commented that there is limited assisted bathing facilities at present due to two baths being out of action, this was discussed with the manager who confirmed that new baths are due to be fitted soon. Alternative bathing facilities were noted to be available. Aldergrove Manor Nursing Home DS0000017175.V306876.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Training opportunities within the home are good which ensures that staff are appropriately skilled and competent to carry out the duties for which they are employed. Although staffing levels within the home meet requirements of registration further review of the staffing structure within the home is needed to ensure that residents needs are consistently met. The home has a robust recruitment procedure in place that protects residents from the employment of inappropriate staff. EVIDENCE: Training records demonstrate that the home continues to provide a good cross section of training to provide staff with the knowledge and skills to meet Aldergrove Manor Nursing Home DS0000017175.V306876.R01.S.doc Version 5.2 Page 20 residents needs and new employees receive induction training that meets the required level. The majority of care staff have attained NVQ level 2 in Care and some staff are in the process of or have attained NVQ level 3. Staff files that were observed contained all the required pre-employment checks confirming that the home operates a robust recruitment procedure, evidence of induction and formal supervision was also available on the files seen. The home is divided into three main areas, which enables individuals with a range of conditions to reside at the home and be cared for by specific staff groups. The minimum required staffing levels for the nursing unit and dementia care unit are documented on the homes CSCI registration certificate in the reception area. The staffing levels for the YPD Unit are not documented but were confirmed as: 4 care staff morning and evening and 2 care staff at night. Staffing levels within each of the units has been looked at during inspections to the home in August 2005 and March 2006. During this inspection a number of residents residing on the nursing and YPD unit felt that the levels were sufficient to meet their needs, other individuals, including relatives and staff did not feel that the levels, particularly on the nursing unit were not always sufficient. The manager appears eager to ensure that staffing levels are sufficient to meet the needs and the dependency of residents and has increased levels on the nursing unit according to need. CSCI is planning to consult with the home to review the staffing levels that are documented on the current registration certificate. Aldergrove Manor Nursing Home DS0000017175.V306876.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has the skills and knowledge to lead the staff team and manage the home. Aldergrove Manor Nursing Home DS0000017175.V306876.R01.S.doc Version 5.2 Page 22 The home is continually monitoring and reviewing processes to ensure that residents receive a good range of quality services. The home is well maintained and the staff group appropriately skilled to ensure that the health, safety and welfare of residents is promoted. EVIDENCE: The manager is a registered nurse with a good range of supporting qualifications, skills and experience and appears enthusiastic in her commitment to improving services within the home. The deputy manager provides continuity for the home in the absence of the manager. Observation of records and discussions with staff confirmed access to regular formal supervision. The home operates a comprehensive process of auditing quality and practice, which includes catering, health and safety, recruitment and medication. Questionnaires are sent out randomly on a monthly basis to residents, relatives and staff and the results are collated and actioned. Senior management conduct monthly, unannounced visits of the home and a copy of this report is sent through to CSCI. The home has robust systems in place to safeguard resident’s financial interests and regular audits are undertaken of financial records to confirm accuracy. Observations during the inspection confirmed a safe environment; bed rails that were observed in use were fitted correctly and moving and handling equipment appeared well maintained. A full range of servicing, maintenance and regular monitoring of services is undertaken and examination of documents showed all to be up to date. Aldergrove Manor Nursing Home DS0000017175.V306876.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 3 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 3 20 X 21 3 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 3 36 3 37 X 38 3 Aldergrove Manor Nursing Home DS0000017175.V306876.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO 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 OP9 Regulation 13 (2) Requirement The temperature of the drugs fridges must be maintained at between 2 and 8°C and the registered person must ensure that staff are aware of the required temperature range and of the procedure to follow should the temperature fall outside this range. The registered person must introduce systems to reduce the temperature of all the treatment rooms within the home to below 25°C. Timescale for action 01/10/06 2 OP9 13(2) 01/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations It is recommended that staff provide more information in the resident’s daily record to demonstrate the nursing input in a residents care. Aldergrove Manor Nursing Home DS0000017175.V306876.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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. Aldergrove Manor Nursing Home DS0000017175.V306876.R01.S.doc Version 5.2 Page 26 - 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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