Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 21/11/07 for Ambleside Residential Home

Also see our care home review for Ambleside Residential Home for more information

This inspection was carried out on 21st November 2007.

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 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 works to maintain the privacy and dignity of the residents. The availability of the complaints procedure ensures that information is available when complaints are raised by residents or on their behalf by relatives. In addition the policy and procedure for protecting residents from abuse is readily available and staff have received training in this area. The home provides a generally clean and well-maintained environment.

What has improved since the last inspection?

Not applicable since the service is classed as `new`.

What the care home could do better:

The home needs to improve its arrangements for assessing and planning the needs of prospective residents. In addition risk assessments must be completed where appropriate for residents and some improvements are needed to medication administration and storage systems. Activities could be further developed through consultation with residents and the use of existing resources. Where special diets are provided a record must be kept in addition to the menu in the interests of monitoring dietary intake.In order to develop a competent staff team there needs to be an assessment of staff training needs and provision of training where required. Staff recruitment practices must be robust to protect residents. All records must be kept in good order and the home must check that it is reporting any incidents in the correct way. Use must be made of the quality assurance tool in the home, so that checks can be made on how the home is being operated in residents` interests.

CARE HOMES FOR OLDER PEOPLE Ambleside Residential Home 69 Hatherley Road Cheltenham Glos GL51 6EG Lead Inspector Mr Adam Parker Key Unannounced Inspection 10:05 21 & 22 November 2007 st nd 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 Ambleside Residential Home DS0000069234.V351411.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ambleside Residential Home DS0000069234.V351411.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ambleside Residential Home Address 69 Hatherley Road Cheltenham Glos GL51 6EG 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) 01242 522937 01242 522937 Perpetual Walsh James Christopher Walsh Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Ambleside Residential Home DS0000069234.V351411.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category (Code OP) The maximum number of service users who can be accommodated is 18. This is the first inspection of a new service. Date of last inspection Brief Description of the Service: Ambleside is a large, detached, Victorian house that has been extended and adapted to provide accommodation for older people. It is situated in a residential area of Cheltenham close to a few shops and the bus route into town, which is approximately a mile away. The railway station is within easy reach, together with a number of churches. Also, there is a local park within walking distance. The accommodation is located on three floors that are all served by a shaft lift and stairs. All the bedrooms have en-suite facilities; approximately five have a bath or shower. There are three bathrooms two of which have hoists. Ground floor communal facilities include a dining room and two lounges one of which has a piano. The lounge at the rear of the property is an extension of the main building and gives an all round view of the large landscaped garden. A patio area provides a pleasant place for service users to sit in warmer weather. A number of car parking spaces are available at the front of the house for visitors and staff. The provider supplies information about the home, including the most recent CSCI report to current and prospective residents on request. The fees range from £426.50 to £580. Hairdressing, chiropody and any personal items are charged extra. The costs of these services are available as required. Ambleside Residential Home DS0000069234.V351411.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The service was taken over by the new providers in 2007 and was therefore classed as ‘new’ for the purposes of this inspection. The registered providers of the home and the acting deputy manager of the home were present for the both days of the inspection visit, which consisted of a tour of the premises and examination of residents’ care files. In addition staff recruitment and training was looked at as well as documents relating to the management and safe running of the home. A sample of residents was selected for inspection against a number of outcome areas as a ‘case tracking’ exercise. During the inspection visit four residents were spoken to, to gain their views of the service. Survey forms were received from 5 relatives of residents, 3 from staff working in the home and 4 from General practitioners (GPs) unfortunately no survey forms were received from residents in the home. An Annual Quality Assurance Assessment (AQAA) form was completed by the home. What the service does well: What has improved since the last inspection? What they could do better: The home needs to improve its arrangements for assessing and planning the needs of prospective residents. In addition risk assessments must be completed where appropriate for residents and some improvements are needed to medication administration and storage systems. Activities could be further developed through consultation with residents and the use of existing resources. Where special diets are provided a record must be kept in addition to the menu in the interests of monitoring dietary intake. Ambleside Residential Home DS0000069234.V351411.R02.S.doc Version 5.2 Page 6 In order to develop a competent staff team there needs to be an assessment of staff training needs and provision of training where required. Staff recruitment practices must be robust to protect residents. All records must be kept in good order and the home must check that it is reporting any incidents in the correct way. Use must be made of the quality assurance tool in the home, so that checks can be made on how the home is being operated in residents’ interests. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ambleside Residential Home DS0000069234.V351411.R02.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ambleside Residential Home DS0000069234.V351411.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Arrangements for assessing prospective residents require improvement in order to check that the home can meet their needs. EVIDENCE: The Statement of Purpose and Service Users Guide were not checked in detail but it was noted that these documents represented the home under the new service provider. It was reported that the registered providers wrote to relatives of residents when they took over the home. The admission and assessment information for the three most recent residents admitted to the home was looked at. All three had funding from the local authority; in two cases information from the local authority had been received although with one of these, this was some time after the resident had been admitted to the home. Ambleside Residential Home DS0000069234.V351411.R02.S.doc Version 5.2 Page 9 However, apart from recording basic information, the home had not completed their own assessment of these residents. With the third resident, no information from the local authority could be found. The registered provider recalled an assessment being carried out by the home but when the assessment document was examined it had only been partially completed. The home does not provide intermediate care and so standard 6 does not apply. Ambleside Residential Home DS0000069234.V351411.R02.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments must be developed for all residents to guide staff in meeting their personal and health care needs, although their privacy and dignity is being upheld. EVIDENCE: Care files for a number of residents were looked at. There were three types of folder in use for care notes and care plans. It was evident that residents recently admitted to the home did not have care plans or risk assessments in place to guide staff in meeting their needs. This included two residents admitted to the home in September 2007. It was reported that copies of care plans were hung on the backs of residents’ doors in their rooms although none were found. Ambleside Residential Home DS0000069234.V351411.R02.S.doc Version 5.2 Page 11 The registered provider had obtained a further format for recording care plans, which also contained risk assessments. This format was planned to be adopted and the use of one file would provide more clarity for staff in reading and completing care documentation. Where care plans did exist they had been reviewed on a monthly basis although with one resident reviews had ceased in August 2007. In addition a risk assessment for falls had not been completed in full with information regarding whether the resident was prone to falling not recorded. Where care plans were in place, there was also recording around daily care needs and preferences and individual information about preferences around sleeping and night time routine such as “two pillows needed.” Dependency profiles had also been completed as well as records of personal care and medical appointments. It was of concern that there were three accidents, one in August 2007 and two in October 2007 where residents had received injuries to their head and no medical advice or attention was sought, one of the accident forms had been signed by the acting manager at the time. Accident records must record if consideration was given to seeking medical advice in the event of an injury and if not then the reasons must be recorded. Evidence was seen of visits to residents in the home by community nurses and mental health nurses. The home provides secure storage for medication. One resident administers their own medication and a risk assessment regarding this had been completed. A refrigerator was in use and temperatures had been monitored and recorded. However no checks had been made of temperatures in the medication storage cupboards. The medication administration records were generally in good order in terms of recording administration with only one omission in recording found. The charts carried photographs of the residents as an aid to recognition when medication is administered. Handwritten directions in the administration charts had not been signed or dated by the staff member making the entry. These should also be checked for accuracy by another staff member. There was no recording of allergies on the medication charts although space for this was provided. Controlled medication was securely stored with appropriate records maintained. Ambleside Residential Home DS0000069234.V351411.R02.S.doc Version 5.2 Page 12 One resident had medication prescribed for anxiety that was to be given when required. There was no care plan or protocol in place to guide staff in when to give this. Such a plan would ensure that the medication is being given in the resident’s best interests. All of the four GPs who completed surveys indicated that the home managed medication appropriately. Training for staff in medication had been planned for October 2007 although this had been cancelled. The home must ensure that all staff who are administering medication to residents have received appropriate training. Staff were observed treating residents with respect and up-holding their privacy. Residents confirmed that staff knocked on doors before entering and were polite to them. Ambleside Residential Home DS0000069234.V351411.R02.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ are able to maintain contact with family, friends and parts of the local community. This provides a good degree of social contact although further development of activities and of the recording of special diets would be of benefit to residents. EVIDENCE: Care files for some residents had an activity log completed. Residents are offered the chance to take part in activities with a musical entertainer visiting the home two days a week. The notice board advertised another musical entertainer who was booked to visit the home in December. A firework party had taken place in November and in August a tea party had been organised for residents and their families. Ambleside Residential Home DS0000069234.V351411.R02.S.doc Version 5.2 Page 14 It was reported that materials have been purchased for residents’ activities and a member of staff had been assigned this role although no progress in this area had been made. One resident was being taken out for walks several times a week by staff. A resident commented that there were not enough activities provided in the home. Another described how she was able to keep herself occupied. During the inspection visit a number of relatives were visiting the home and some were taking residents out. In surveys two relatives commented positively on how they were made to feel welcome when they visited the home. Holy Communion is provided in the home once a month and a mobile library visits. Seasonal activities were being planned for Christmas. The home has information about advocacy services The home has a menu that runs on a four weekly basis. A cooked lunch is provided and in the evening supper consists of sandwiches. One resident said how much these were enjoyed. One resident was eating a vegetarian diet; this did not feature on the menu so a separate record must be kept. The cook confirmed that there were sufficient supplies of food for the residents’ needs. Residents spoken to described the meals as “pretty good” and “very good indeed” and one said she was “well fed”. Ambleside Residential Home DS0000069234.V351411.R02.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s policies on complaints and preventing abuse should protect service users from harm although training in this area for all staff would be of benefit to people who use the service. EVIDENCE: The home’s complaints procedure was clearly displayed in the entrance hall. In addition it is contained within the Resident’s Handbook (service user’s guide). One complaint letter had been received and the written response to this was examined. The complaints and concerns procedure states “The manager will acknowledge your complaint within 4 days and respond to a complaint in writing within 28 days with the aim to rectify the situation following investigation.” Out of seven survey forms received from relatives of residents four indicated that they knew how to make a complaint, two indicated that they did not and one stated, “I have had no need to complain and as the staff are always available they would be my first point of contact.” Ambleside Residential Home DS0000069234.V351411.R02.S.doc Version 5.2 Page 16 The policy and procedure for protecting residents from abuse was looked at. This was displayed near the entrance of the home and made reference to contacting other agencies if the need should arise. Staff training in abuse had taken place under the previous provider although at the time of the inspection no information was available about how many staff had attended the training. A notification regarding the alleged misconduct of one of the registered providers towards a resident had been notified to the Commission although full details had not been provided at the time of the inspection it was reported that an investigation had been undertaken. This was discussed with the registered providers at the inspection. Ambleside Residential Home DS0000069234.V351411.R02.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have the benefit of living in a well-maintained and generally clean, environment with personalised individual rooms. EVIDENCE: A tour of the premises revealed that the home was generally clean, well decorated and well maintained. Communal areas consist of a lounge at the front of the home, a dining room adjacent to the kitchen and a rear lounge that was particularly light and overlooked the extensive rear garden. Outside there were two patio areas accessible to residents. CCTV equipment was noted to be installed in a number of communal areas of the home although the cameras were no longer functioning and the monitoring equipment was disconnected. An explanatory notice was on the front door and this should be removed. Ambleside Residential Home DS0000069234.V351411.R02.S.doc Version 5.2 Page 18 Individual rooms showed various degrees of personalisation and were clean although there were odours in two rooms. The acting manager and the registered provider were aware of these and had plans to remedy the problem. Some rooms had small refrigerators. Rooms had locks fitted on the doors suitable for resident’s use and lockable drawers were available. There were maintenance issues in two rooms, one with a missing light bulb and one where a sliding door to the ensuite that had become detached. These were promptly attended to during the two days of the inspection visit. Following repairs to the roof of the building some remedial work needed to be done to the damage to the plasterwork on the stairway. Radiators in residents’ bedrooms were covered although there were a number of uncovered radiators in communal areas, including a large radiator in the front lounge that was hot to the touch. A risk assessment exercise must be carried out to determine if these pose any risk to residents. The laundry was tidy, well organised and had recently been painted. Hand washing facilities were available in the laundry and in a number of other locations in the home. It was noted that care staff carried individual bottles of hygienic hand gel. Ambleside Residential Home DS0000069234.V351411.R02.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The lack of staff numbers and training may affect the ability of the home to meet the needs of people using the service. This in conjunction with poorly developed recruitment procedures may put residents at risk. EVIDENCE: On the first day of the inspection visit the home was short-staffed with a cook, a cleaner and one carer absent from the shift. It appeared however that staff were managing and residents spoken to said that they had not noticed any problems from the staff shortages. The afternoon and night shifts were staffed according to the rota. At weekends a senior carer works on each shift and the acting deputy manager is ‘on-call’. Two residents spoken to about staff shortages were aware of these but said they had “no issue” with the staffing and one confirmed that she had coped. However the home must ensure that staffing levels suitable for the residents’ needs are maintained. The home has less than 50 of its care staff trained to NVQ level 2 although there are 3 staff with an NVQ level 3. The home should improve the numbers of care staff with an NVQ. Ambleside Residential Home DS0000069234.V351411.R02.S.doc Version 5.2 Page 20 Although it was reported that there had been no new staff recruited since the new providers had taken over the home it later transpired that a member of care staff previously employed in the home had returned to work ‘bank’ shifts when required. This person must be subject to full employment checks including a criminal records bureau disclosure. An outside contractor had been used to paint the outside of the house, although he had taken on more work that had brought him into contact with residents. During the inspection visit he was applying for a Criminal Records Bureau check although this check should have been made at an earlier stage. The home was also in the process of recruiting four staff. The documentation obtained for these was examined. Two of the applicants had not provided an employment history. This was discussed with the registered provider during the inspection. Any employment of new staff would lead to the need for induction training therefore the home should give consideration as to how this would be provided. Some staff training courses had been cancelled; this was reported to be due to the fact that not enough staff were able to attend. The general training needs of staff must be assessed and a plan put in place to meet these. Ambleside Residential Home DS0000069234.V351411.R02.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The absence of robust and experienced management and a lack of quality monitoring systems needs to be addressed as a matter of urgency to ensure the home is always run in the best interests of people using the service. EVIDENCE: The previous registered manager had resigned from the home in July 2007. An acting manager and a deputy manager had been running the home but neither were working in the home at the time of the inspection. A senior carer was working in an acting management role. Ambleside Residential Home DS0000069234.V351411.R02.S.doc Version 5.2 Page 22 Whilst it is acknowledged that the new proprietors are trying to resolve the management issues in the home, the Commission is concerned that current and future residents could be vulnerable to inadvertent poor practice and the failure to properly record and notify events which could place them at risk. When the management situation in the home is resolved the registered provider must ensure that an application is made for the registration of a manager at Ambleside. The home has two quality assurance folders; these would provide an excellent basis for a quality assurance system. Unfortunately no use had been made of these documents. Reports had been compiled following visits to the home by the registered provider. These must be forwarded to the Commission. The home provides secure facilities for residents’ money and valuables if required. During the inspection visit access to this facility was not available. The home was awaiting the return of the deputy manager who held the key. In the meantime money for any hairdressing or chiropody appointments was being paid by the registered provider on behalf of the residents. Records kept in the home were not kept in good order with files piled up in no particular order in the manager’s office making some documents difficult to locate. Staff have received training in fire safety and first aid although training in manual handling had been cancelled. Notification regarding incidents in the home had not been given to the Commission. These included a resident being admitted to hospital with a serious illness and their subsequent death and a resident being admitted to hospital following a fall. The accident records were examined; these are subject to a monthly audit. A number of accidents to residents were noted. Required improvement to this recording are mentioned in the text for Standard 8. The central heating system had been serviced as well as the electrical wiring, portable electrical appliances hoists and the lift. Work had been carried out in respect of any potential risk to residents from Legionella number of hot water taps in residents’ rooms were checked and although the temperatures were not measured there was a noticeable variation. The home must keep a regular check on temperatures and make any necessary adjustments in the interests of residents’ safety and comfort. Ambleside Residential Home DS0000069234.V351411.R02.S.doc Version 5.2 Page 23 Cleaning substances carried around the home on the cleaning trolley were examined. A number of these had been decanted into unmarked spray bottles from larger containers and one was said to contain diluted bleach. In order to provide information for staff in the event of any accidental contact with these substances by residents, containers must be accurately labelled. A problem with rats in the laundry was being dealt with at the time of the inspection visit. Ambleside Residential Home DS0000069234.V351411.R02.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X 3 2 3 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 2 X 2 2 Ambleside Residential Home DS0000069234.V351411.R02.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Not applicable. 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 OP3 Regulation 14 (1) (a) & (b) Requirement A copy of any assessment or care plan from any funding authority must be obtained by the home before a resident is admitted so that the home can check if it can meet their needs. All residents must have care plans to guide staff in meeting their needs. Care plans must be kept under review to ensure that they reflect residents’ current needs. Records of accidents to residents must state if medical advice has been sought and if not the reasons for this. Where directions are hand written in medication administration charts these must be signed and dated by the staff member making the entry and checked and signed by another staff member to ensure accuracy. Timescale for action 31/12/07 2 OP7 15 (1) 31/01/08 3 OP7 15 (2) (b) 31/01/08 4 OP8 13 (1) (b) 31/12/07 5 OP9 13 (2) 31/01/08 Ambleside Residential Home DS0000069234.V351411.R02.S.doc Version 5.2 Page 26 6 OP9 13 (2) 7 OP9 13 (2) 8 OP15 9 OP25 17 (2) Schedule 4 Paragraph 13 13 (4) (a) & (c) 18 (1) (a) 10 OP27 Where medication is prescribed for residents on an ‘as required’ or ‘PRN’ basis then there must be a care plan or individual protocol in place to guide staff in administration. This will ensure that residents receive medication when necessary and in line with planned actions. Staff who administer medication to residents must have appropriate training so that medication is administered safely When an alternative meal is provided for a resident this must be recorded. This will ensure that a check can be made on dietary intake. A risk assessment exercise must be carried out on any unguarded radiators to establish the level of risk to residents. In order to meet residents’ needs the home must ensure that it has suitable staffing levels at all times. Before a person starts work in the home, all the information and documents specified in Schedule 2 of the Care Homes Regulations must be obtained to ensure that residents are protected through robust recruitment procedures. Staff training needs must be identified and recorded in order to plan for providing training to enable residents to be cared for by a competent staff group. 31/01/08 29/02/08 31/12/07 29/02/08 31/12/07 11 OP29 19 (1) (b) Schedule 2 31/12/07 12 OP30 18 (1) (c) (i) 31/01/08 13 OP31 Care An application to register a Standards manager at the home must be Act made. Section 11 (1) DS0000069234.V351411.R02.S.doc 29/02/08 Ambleside Residential Home Version 5.2 Page 27 14 OP33 24 (1) (a) & (b) The registered person must ensure that there is a system for reviewing and improving the service provided in the home based on the views of the home by service users and their representatives. The registered person must supply copies of reports compiled under regulation 26 to the Commission until further notice. To ensure residents’ safety and comfort, regular checks must be made with records kept on the temperatures from hot water outlets. All cleaning materials must be kept in correctly labelled containers so that there is information readily available to deal with any unwarranted contact with these materials by residents. The registered person must give notice to the Commission without delay of the occurrence of any event in the care home specified under regulation 37. 31/03/08 15 OP33 26 31/12/07 16 OP38 13 (4) (a) & (c) 31/01/08 17 OP38 13 (4) (c) 31/12/07 18 OP38 37 31/12/07 Ambleside Residential Home DS0000069234.V351411.R02.S.doc Version 5.2 Page 28 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 OP3 Good Practice Recommendations Where the home carries out its own assessment of any prospective resident then this should be completed in full and signed and dated by the person carrying out the assessment. The temperature in the medication storage cupboards should be monitored and recorded to check that residents’ medication is being kept at the correct temperature. It should be recorded if any allergies are known or not on residents medication administration records. Further develop the provision of activities in the home through consultation with residents and use of resources. The notice on the front door regarding CCTV cameras should be removed. The home should improve the number of care staff with an NVQ level 2. The home should consider how induction training would be provided to new staff. Records should be kept in a good state of order so that information can be easily found. 2 3 4 5 6 7 8 OP9 OP9 OP12 OP19 OP28 OP30 OP37 Ambleside Residential Home DS0000069234.V351411.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South West Regional Office Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ambleside Residential Home DS0000069234.V351411.R02.S.doc Version 5.2 Page 30 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!