Inspection on 01/02/06 for Ardenlea Court

This inspection was carried out on 1st February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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.

Other inspections for this house

Ardenlea Court 30/07/08

Ardenlea Court 05/06/07

Ardenlea Court 05/07/06

Ardenlea Court 20/09/05

Ardenlea Court 15/02/05

Ardenlea Court 05/10/04

Ardenlea Court 20/01/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Ardenlea Court 39-41 Lode Lane Solihull West Midlands B91 2AF Lead Inspector Ann Farrell Unannounced Inspection 1st February 2006 08:30 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 Ardenlea Court DS0000004566.V281377.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. Ardenlea Court DS0000004566.V281377.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ardenlea Court Address 39-41 Lode Lane Solihull West Midlands B91 2AF 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) 0121 711 7773 0121 711 2235 BUPA Care Homes (BNH) Limited Vacant Care Home 63 Category(ies) of Old age, not falling within any other category registration, with number (63), Physical disability (63), Terminally ill (5) of places Ardenlea Court DS0000004566.V281377.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May provide accommodation, nursing, and personal care for up to 5 people requiring palliative care over 65 years of age. May provide intermediate care for up to 18 people over 50 years of age, which may include care and nursing needs related to sickness, injury and infirmity. Intermediate care services must be provided from the dedicated accommodation identified for this purpose within the home and must be supported by equipment and staffing appropriate for its specific intermediate care function. Rehabilitation facilities and equipment must not impinge upon or reduce the communal space available to non-intermediate care service users. May provide accommodation for one named resident under 65 years of age requiring palliative care. 20th September 2005 3. 4. 5. Date of last inspection Brief Description of the Service: Ardenlea Court is a purpose built Care Home that is owned and managed by BUPA Care Homes Ltd. The home provides personal care and nursing for up to sixty-three residents over the age of 65, who are frail elderly and/or physically disabled. Of the sixty-three beds available eighteen of them are under contract with the Solihull Primary Care Trust to provide intermediate care to patients following transfer from hospital. These beds are used for patients of 50 years and older falling within the following categories; sickness, injury, infirmity, surgical or investigative care and are situated on the ground floor. In addition, up to 5 beds are registered to provide care to residents requiring palliative care. The home is situated within walking distance of the centre of Solihull. The M42 is about two miles away and the bus and rail services are easily accessible. The property is adjacent to private housing accommodation. There is a paved garden to the rear of the property providing a seating area and there is adequate car parking space at the front of the building. Access for wheelchair users is good. There are no steps to the front door. The home has a passenger lift situated in the main corridor, which provides access to all areas inside the building. All bedrooms have en-suite facilities and there are assisted bathing facilities situated around the home. Ardenlea Court DS0000004566.V281377.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was conducted over one full day commencing at 8.30am on 1st February 2006. This is the second statutory inspection for the year 2005-2006 and it is recommended that this report be read in conjunction with the previous report. The manager was present for the duration of the inspection. During the inspection process the inspector sampled residents files and case tracking was undertaken in respect of a small number of residents, in addition to inspection of other documentation relating to the management of the home. The manager, nine members of staff and eight residents were spoken to. On discussion with residents they were appreciative of the work by staff and stated they did everything they could, but felt there were not sufficient staff on duty at all times. All the requirements from the last inspection were not inspected and some have been carried forward. What the service does well: The home is furnished and decorated to a high standard providing pleasant surroundings for residents to live. The environment is well maintained and cleaned to a good standard. There is a relaxed atmosphere and the manager’s office is situated in the main reception area, enabling visitor’s easy access to discuss any issues or concerns. Visiting arrangements are flexible. There is a separate intermediate care unit on the ground floor and staff have good relationships with the Primary Care Trust and other health professionals. The G.P. was visiting and stated he found all the nurses good; they carried out instructions and called the doctors out appropriately. Feedback from residents indicated that staff are good. One resident stated “They do everything they can for you”. The home offers adaptation training to one nurse each year. There is a menu with a choice of meals and alternatives are available upon request. Ardenlea Court DS0000004566.V281377.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Further improvements are required in respect of the medication system to demonstrate that all residents receive the medication prescribed by doctors. The home must demonstrate robust systems are in place for responding to emergency calls in life threatening situations. The home must provide sufficient equipment for moving and handling residents to meet their needs at all times e.g. rising, retiring, toileting etc. The meal needs to be improved further with more variety and systems need to be in place to ensure that all residents are offered alternatives to the menu plus supper. In addition, communication with the catering staff needs to be enhanced to ensure they are aware of any special diets for residents. The general communication and management systems need to be reviewed and action taken to address, shortfalls to include such areas as staff supervision, staff meetings etc. The process of assessment and care planning needs to be improved to ensure all residents’ needs are identified and an accurate plan drawn up to outline in detail how resident’s needs are to be met. Systems need to be in place to ensure they are implemented utilising interventions outlined in the plan of care e.g. for falls. The manager must ensure there is sufficient staff on duty at all times to meet residents needs and this must be increased with any increased dependency of residents. Further staff training is required in basic and specialised areas to provide staff with the skills and knowledge to meet resident’s needs. Ardenlea Court DS0000004566.V281377.R01.S.doc Version 5.1 Page 7 Some re-decoration is required and the work on the quiet lounge on the first floor needs to be completed to enhance the environment for residents. The manager stated that the remaining bedroom doors are to be linked into the fire alarm system. 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. Ardenlea Court DS0000004566.V281377.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ardenlea Court DS0000004566.V281377.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4 Assessments need to be developed further in order to facilitate staff in meeting all resident’s care requirements. Further staff training, equipment and robust systems for summoning help in life threatening situations needs to be in place to meet residents needs. EVIDENCE: A service user guide is available in resident’s rooms. At the last inspection it was recommended that this be made available to prospective residents to enable them to make an informed decision about moving into the home. On discussion with the manager it appears no changes have been made in this area. A way forward was agreed as she visits residents prior to admission to undertake an assessment to determine if the home is able to meet their needs. The home has a designated area on the ground floor for eighteen residents who are admitted for reason of intermediate care. The residents on this unit are admitted for reason of aided recovery or admission prevention to hospital. There are separate staffing arrangements with two nurses and five carers on duty during the day. They liaise closely with physiotherapists and occupational therapists and have a separate therapy room to assist with rehabilitation of Ardenlea Court DS0000004566.V281377.R01.S.doc Version 5.1 Page 10 residents, enabling them to return home. The majority of long-term residents are accommodated on the first floor. Staff utilise the assessment from social workers and also undertake a preadmission assessment to determine if they are able to meet the needs of prospective residents. Upon admission further documentation is completed to include risk assessments in respect of nutrition, tissue viability, manual handling etc. enabling staff to draw up a care plan. However, some of the records lacked detail, were not signed and dated The home is registered to care for older people in need of general nursing care, however, a number of residents have lived at the home for a period of time and have additional dementia care needs. It was stated that two nurses have undertaken training in respect of caring for residents with dementia and they are to cascade the training to the remainder of the staff in the home. There is one active and one passive hoist on each floor. At the time of inspection there was only one handling belt, which was damaged and one sliding sheet for general use on the first floor. Sliding sheets should not be used from one resident to another due to the risk of cross infection. On discussion with some residents on the first floor, who required the hoist, they stated they had to wait for attention as the hoists were in use. Currently there are 56 of residents on the first floor who require the use of a hoist, which may increase with full occupancy. Staff on the first floor have borrowed the hoist from the ground floor at times to meet residents needs, but both floors tend to use the hoist at the same time of day for toileting purposes etc. On discussion with staff on the ground floor it was apparent that there were five residents who required a hoist on a permanent basis plus one resident from intermediate care who had just been discharged. If they require any further equipment on the ground floor it was stated the physiotherapists provide it. The manager must ensure there is adequate equipment to moving and handling residents to meet their needs at all times An immediate requirement was left with the home to provide additional handling equipment in the first floor to include a hoist, handling belts and sliding sheets. A response has been received from the organisation stating that they believe they provide suitable arrangements to provide a safe system for moving and handling residents. However, they will undertake some evidence gathering to ascertain the dependency of residents and practices in the home and review the situation. Although there is a call bell in each room it was noted that only some of the staff have a pager to alert them of calls. At one time during the inspection a carer had to run up the corridor to alert the nurse of an emergency call on the other floor. This is very concerning as the carer may have been busy with a resident and unable to leave them or the carer may not have been able to find Ardenlea Court DS0000004566.V281377.R01.S.doc Version 5.1 Page 11 the nurse if they were away from the nurses station. An immediate requirement was made for the home to provide all staff with a pager when they are on duty. The organisation has responded by saying that in their opinion the current system meets the needs of residents in the home as they provide a call bell in each room and they monitor it through a recording system to see if calls for assistance are responded to in an appropriate time. They believe the current system is effective. The manager must be able to demonstrate a robust system or summoning assistance in an emergency where there is a life-threatening situation. Ardenlea Court DS0000004566.V281377.R01.S.doc Version 5.1 Page 12 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): 7, 8, 9, 10 Care planning systems need to be developed further to ensure all residents needs are met and there is adequate supervision at all times. The systems for medicine management have improved since the last inspection. These need to be enhanced further to ensure residents medication needs are met. EVIDENCE: Staff had drawn up care plans for all residents and a sample were inspected. It was noted that they were not comprehensive, details were vague and there were some inaccurate details e.g. one stated that some equipment was in place and in fact it was not present. It also stated that he physiotherapist had left instructions about the method for handling a resident. The instructions were not available in the care plan or the resident’s room and when they were found they lacked detail. It was noted that a risk assessment in respect of tissue viability was high, but there was no indication of any action taken. A falls risk assessment for one resident had not been reviewed monthly or following falls and there was no indication that any action had been followed as outlined in the plan of care as this resident was experiencing a number of falls. The manager must ensure all care plans are accurate responding to interventions provided and outline in detail the action required by staff to meet residents needs in a consistent manner. There must be systems in place to Ardenlea Court DS0000004566.V281377.R01.S.doc Version 5.1 Page 13 ensure care plans are implemented fully and appropriate interventions implemented e.g. following falls. All residents are registered with a local G.P. practice and doctors undertake regular visits to the home each week and in between if required. Staff liaise with health professionals from the multidisciplinary team as required. The G.P. was visiting at the time of inspection and stated he found the nurses on both floors were very good; they carried out instructions and called doctors appropriately. On inspection it was noted some residents did not have access to a call bell and lounges were not supervised. Also some beds only have one bed rail in place. The manger must undertake an audit of all beds and ensure that where bed safety rails are used there is one on each side of the bed and they are of sufficient height to ensure residents safety. Records indicate that there are a large number of residents having falls. The manger will need to review systems to ensure closer supervision of residents and interventions for the reduction in falls. On discussion with residents they stated staff were very good. “Staff do what ever they can for you, they are very busy”. Another stated, “the staff are run ragged and they need extra staff”. On discussion with another resident she was happy with the care, but like more frequent baths. The home receives medication regularly and the pharmacist inspector undertook an inspection. It was found that the nurse on duty on the ground floor unit was seen signing the Medicine Administration Record (MAR) chart after the drug round had finished. Inadequate checks of medicines received had taken place and quantities of medicines received or balances carried over had not been routinely recorded so auditing medicines to demonstrate that they had been administered as prescribed were difficult to perform. All medicines were administered correctly from the Monitored Dosage System. Audits demonstrated that medicines administered from ordinary containers dispensed by the pharmacist were not always administered correctly or accurately recorded. Hand written MAR charts were generally good, but some recorded ambiguous directions that may result in an inadvertent drug administration error. Residents wishing to self-administer their own medication are supported to do so, but there was no evidence of any risk assessments or compliance checks undertaken. Both medication rooms were clean and tidy and well organised. The home has a good relationship with the doctors and the community pharmacist. The home is registered to care for residents for reason of palliative care, but staff have not received any training in this area. Ardenlea Court DS0000004566.V281377.R01.S.doc Version 5.1 Page 14 All bedrooms have locks to doors and many have lockable facilities. Rooms have telephone points and portable trolley telephones are available. Ardenlea Court DS0000004566.V281377.R01.S.doc Version 5.1 Page 15 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): 12, 15 Residents reported that there had been improvements in the social activities. The arrangements for meals and snacks need to be developed further and better communication with catering staff to ensure residents receive special diets and varied meals. EVIDENCE: Residents are free to come and go as they wish and there are no rigid rules. There is a relaxed and welcoming atmosphere when entering the home and visiting is flexible. The home has employed staff to undertake the role of activities co-ordinators for twenty hours per week. Feedback from residents indicated that there had been improvements in this area and some had been out to a pantomime recently. There is a separate hairdresser’s room and she visits weekly. Residents are offered three full meals a day with a choice at all meals. They are consulted about the menu on a daily basis and where they do not want either choice on the menu it was stated an alternative is available, but on discussion with residents they were not aware of this. Also residents stated that supper is not routinely offered to them. One resident who had been in the Ardenlea Court DS0000004566.V281377.R01.S.doc Version 5.1 Page 16 home for almost a week informed the inspector he had only had one hot meal since he had been in the home and had received mainly sandwiches. The same resident was on a special diet and the kitchen staff were not aware of it. Apparently there have been problems with communication between care staff and the catering staff in the past regarding special diets. On discussion with residents the comments indicated that the food was adequate at times. One resident stated “the food is O.K., it is better than hospital food” and another stated, “The menus needs more imagination”. This area needs continued development and improvement. Tables were laid appropriately for lunch, fresh fruit was available. Staff were available and responded to residents requests appropriately providing assistance where required. Ardenlea Court DS0000004566.V281377.R01.S.doc Version 5.1 Page 17 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 The procedures in respect of complaints and protection from abuse need to be developed further to ensure residents are adequately protected. EVIDENCE: The home has a complaints procedure and a copy is available in the service user guide, which is in resident’s rooms and is accessible to residents and relatives. There is also a copy displayed on the wall in the reception area, but it is not in a prominent place. On discussion with some residents they stated they were not aware of the complaints procedure. It is recommend that this be discussed with residents in their meetings advising them of the procedure and where they can access copies. It is also recommended that the complaints procedure be situated in a more prominent position in the reception areas. Some staff have undertaken training in respect of the adult protection procedures, but on discussion with some staff there was some hesitation in their responses. The manager must ensure that all staff are fully aware of the action to take in the event of any allegation including the whistle blowing procedure. The home has a separate adult protection procedure, which needs reviewing to ensure it is in line with local guidance. Ardenlea Court DS0000004566.V281377.R01.S.doc Version 5.1 Page 18 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, 20, 21, 22, 23, 24, 25, 26 The décor and furnishings are of a good standard and provide a homely and pleasant environment for residents to live EVIDENCE: Ardenlea Court DS0000004566.V281377.R01.S.doc Version 5.1 Page 19 The home is a modern two-storey building, which is cleaned to a good standard and well maintained. There is access to all areas via a passenger lift. There is a dining room and lounge on each floor, which are pleasantly decorated and furnished. In addition, there is seating in the reception area. The small lounge on the first floor is in the process of being converted in to two bedrooms and the bedrooms are being converted in to the lounge, so providing the same facilities for residents. All bedrooms are provided with en-suite facilities and a call bell, which can be moved to any position, enabling residents to sit wherever they wish. All bedroom doors have a lock and the manager is in the process of consulting residents as to whether they wish to have a key. Some rooms have lockable facilities for valuables or medication. The manager will need to ensure that all rooms have lockable facilities with keys available that may be used by residents if they wish. A number of bedrooms had been personalised by residents and many were decorated to a good standard. Some require re-decoration and the manager stated they would be addressing these areas in the coming year. All areas inspected were cleaned to a good standard. In addition to the en-suite facilities there is a range of assisted baths and showers on each floor and toilets are strategically placed through the home. It was noted that the sealing around the bath in bathroom 7 required attention. Rooms are individually and naturally ventilated and windows are provided with restrainers for safety and security reasons. Radiators are of the low surface temperature type and water from hot water outlets is regulated to reduce the risks of accidents from scalds. Since the last inspection the bedroom doors on the first floor have been linked into the fire alarm system so that residents can keep them open if they wish. Bedroom doors on the ground floor are still being propped open, but the manager stated that they are to be linked onto the fire system in the near future. The main kitchen is situated on the ground floor and was well maintained. It was noted that the chopping boards need replacement, the knives need sharpening and some serving spoons and meat tins are required. The door to the satellite kitchen on the first floor was not locked when unattended and may pose a risk to residents. Ardenlea Court DS0000004566.V281377.R01.S.doc Version 5.1 Page 20 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, 28, 29, 30 There have been improvements in the staff recruitment procedures. The number of staff on duty is not consistently maintained at adequate levels to meet resident’s needs. Further training in NVQ level 2 is required to provide staff with the appropriate skills and knowledge. EVIDENCE: The ground and first floor are staffed separately due to the difference in client group. The first floor can accommodate twenty-nine residents who require long term nursing care and they also have five places for residents who require palliative care, which may have implications in respect of higher dependency and emotional support for resident and family. At the time of inspection there was 23 residents on the first floor and there were six staff on duty during the morning and five on the afternoon shift. This appeared adequate at the time of inspection, but would need to be increased when there is at full occupancy. The ground floor has two nurses and five care staff on duty during the day. On inspection of duty rotas and discussion with staff it was apparent that these staffing levels are not maintained consistently for either floor. Also some staff work long day shifts in the home, which necessitates them taking lunch breaks of one hour at busy times in the home. There are no rostered handover periods between shifts, which means that there are periods when staff are having a report and are not available to respond to residents. There is only one nurse on each shift on the first floor, which results in no nurse being on the floor then they take a break or lunch. The manger must ensure that staffing levels are maintained to meet resident’s needs at all times and Ardenlea Court DS0000004566.V281377.R01.S.doc Version 5.1 Page 21 increased where there is an increased dependency. Where they cannot provide sufficient staff of their own to cover shifts they must use alternative arrangements such as agency or bank staff. It was stated that induction training is given to new staff; they are supernummary for two days and are provided with a training manual and mentor to support them. On discussion with some new staff they were not aware of the mentorship system. A small number of staff files were examined in respect of newly employed staff and it was found they had references, proof of identity and POVA check, but there was no evidence of CRB’s available. The home must have evidence of CRB check available in the home. If they wish to make alternative arrangements they must write to the Commission formally with a request outlining any alternative arrangements they wish to put in place. The manger will need to ensure that staff files for all existing staff are of a similar standard to demonstrate a robust recruitment procedure. Ardenlea Court DS0000004566.V281377.R01.S.doc Version 5.1 Page 22 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, 36, 38 The maintenance aspects of the home are well managed and there has been some staff training since the last inspection. Staff supervision, quality assurance, communication and management systems need to be reviewed and developed to ensure the home addresses shortfalls, develops and continues with a commitment to residents. EVIDENCE: The manager has been in post for approximately one year and has applied to the Commission for registration. It was stated that training had been undertaken since the last inspection to include moving and handling for all new staff and infection control. Fire training has commenced and is ongoing. One member of staff is the manual handling training and is allowed time to provide the training, but does not get time to undertake assessment of practice. Areas where further training is Ardenlea Court DS0000004566.V281377.R01.S.doc Version 5.1 Page 23 required include basic food hygiene training and first aid/emergency resuscitation training. Records of training were not up to date to demonstrate the training that had been undertaken. The manger will need to ensure records are up to date and a matrix is available for easy reference. The home has a large number of incidents involving residents falling, but there has been no auditing and there appears to be no specific strategies for reducing/preventing falls. The manger will need to review this area; undertake audits and introduce a range of strategies for the reduction/prevention of falls. On discussion with a number of staff it was stated that there is a lack of communication and management support in the home. Evidence indicated that staff supervision is not occurring and staff meetings are not occurring regularly. On discussion with the manager she stated nurses would undertake supervision, but it appears that they have not received any training in this area. As outlined in care plans The manger stated that there was a customer satisfaction survey in December 2005, but had not received any feedback. The manger will need to ensure a quality assurance process is implemented, which is based on all stakeholders’ views and draw up an annual development based on outcomes for residents. Ardenlea Court DS0000004566.V281377.R01.S.doc Version 5.1 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 2 X 2 1 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 3 3 2 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 1 1 X X 1 X 2 Ardenlea Court DS0000004566.V281377.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 5 Requirement The registered person must ensure systems are in place to provide prospective residents with a service user guide. The registered person must: • Ensure a comprehensive assessment of all residents is undertaken upon admission to the home. • Review the manual handling assessment and update to include details of the action to be taken if a resident falls on the floor. Timescale of 15/11/05 not met. The registered person provides sufficient equipment for moving and handling residents on the first floor to include handling belt, sliding sheets and hoist. An immediate requirement was made. The registered person must be able to demonstrate a robust system is in place to respond to an emergency calls in life threatening situations. An immediate requirement was made. DS0000004566.V281377.R01.S.doc Timescale for action 28/02/06 2. OP3 14 30/03/06 3 OP4 12(1) 28/02/06 4 OP4 23(2)(n) 13(4)(c) 15/02/06 Ardenlea Court Version 5.1 Page 26 5. OP4 18(1) 6. OP7 15 7. OP8 12(3) 8 OP8 13(4) 9. OP8 12(1-4) The registered person must ensure all staff undertake training in respect of caring for residents with dementia commensurate with their position in the home. Timescale of 30/7/05 not met. The registered person must ensure; • All nursing staff complete a comprehensive and accurate care plan outlining how residents needs are to be met following assessment. • The care plans must include all areas of need. • Care plans must be reviewed at least once a month and updated when there are any changes. Timescale of 30/5/05 not met. • The registered person must ensure care plans are implemented with appropriate interventions e.g. where a resident has a number of falls The registered person must ensure all residents are consulted about their preferences in respect of bathing, it is recorded and arrangements are made to meet their needs. The registered person must undertake an audit of all bedrails ensuring there is one on both sides of the bed and they are of a suitable height to maintain residents safety. The registered person must ensure there is adequate supervision of residents in all areas and call bells are consistently available. 30/06/06 30/03/06 30/03/06 28/02/06 20/02/06 Ardenlea Court DS0000004566.V281377.R01.S.doc Version 5.1 Page 27 10 OP9 13(2) 11 OP9 13(2) 12 OP11 18(1) The registered person must 01/03/06 ensure: • All prescriptions must be seen prior to dispensing and a system installed to check the dispensed medicines and the Medicine Administration Record (MAR) chart for accuracy. These must be kept alongside the relevant MAR chart for reference. • The quantities of medicines received or the balance carried over from previous cycles must be recorded to enable accurate audits to take place to demonstrate that the medicines are administered as prescribed. • Staff drug audits before and after a medicine round are undertaken to confirm nursing staff competence in medicine management. Appropriate action must be taken when discrepancies are found. • Any resident wishing to self administer their own medication are risk assessed as able and regular compliance checks must be undertaken and documented to ensure the safety of the resident. The registered person must 02/02/06 ensure: • The MAR chart is referred to before the administration of medicines or the reasons for non-administration recorded directly after the transaction. The registered person must 30/06/06 ensure all staff receive training DS0000004566.V281377.R01.S.doc Version 5.1 Page 28 Ardenlea Court 13 OP12 16(2m&n) 14. OP15 16(2i) 15. OP16 22 16. OP18 13(6) in respect of palliative care commensurate with their position in the home and records are retained. The registered person must ensure an assessment is undertaken in respect of residents past interests and hobbies and a plan of activities drawn up (individual or group) implemented and records are retained in the home. This area was not assessed and has been carried forward from 20/1/04. The registered person must ensure: • Arrangements are in place for residents to be offered supper on a daily basis. • Arrangements are in place to offer residents an alternative to the main menu. • Communication systems are improved to ensure that catering staff are made aware of any special diets. • All residents are offered at least one full hot meal every day and they receive a varied nutritious diet. The registered person must ensure all residents and their representatives are aware of the complaints procedure. The registered person must ensure: • All remaining staff undertake training in respect of the vulnerable adult and whistle blowing procedures and the action to take in the event of an allegation of abuse. • The homes adult protection procedures are reviewed DS0000004566.V281377.R01.S.doc 30/03/06 20/02/06 30/03/06 30/03/06 Ardenlea Court Version 5.1 Page 29 17. OP19 23(4) 18 OP19 13(4) 19. OP19 16(2g) 20. 21. OP24 OP27 23(2d) 18(1) 12(1) 22. 23. OP28 OP29 18(1) 19 and updated in line with local guidance. The registered person must advise the Commission of the date when the bedrooms on the first floor are to be converted into the lounge. The registered person must ensure the satellite kitchen on the first floor is kept locked when not attended by staff. The registered person must: • Replace the worn chopping boards. • Ensure the knives are sharpened. • Provide adequate numbers of serving spoons and meat tins. The registered person must audit the home and re-decorate as required. The registered person must ensure there are adequate staff on duty at all times to meet residents needs and this must be adjusted where there is any increase in residents dependency. Timescale of 30/10/05 not met. The registered person must ensure at least 50 of care staff are trained to NVQ level 2. The registered person must: • Ensure staff files for all existing staff include proof of identity, right to work in the country, references, POVA check and CRB. • Contact the Commission formally in writing if they wish to make alternative arrangements for the storage of CRB checks. 30/03/06 02/02/06 30/03/06 30/07/06 15/02/06 30/09/06 30/03/06 Ardenlea Court DS0000004566.V281377.R01.S.doc Version 5.1 Page 30 24. OP30 18(1) The registered person must ensure all new staff undertake induction training, are aware of the mentor system and records are retained in the home. The registered person must ensure there are suitable and adequate communication and management systems in the home to include regular staff meetings. The registered person must ensure there is a quality assurance process in the home based on seeking feedback from all stakeholders and draw up an annual development plan indicating outcomes for residents. The registered person must ensure: • All staff in the home have formal supervision at least six times per year and records are retained in the home. • Staff who undertake supervision must undertake training to provide them with the appropriate skills. The registered person must ensure remaining staff undertake updated training in respect of manual handling and records are retained in the home. Timescale of 30/6/05 not met. The registered person must ensure all staff undertake training in respect of basic food hygiene. The registered person must ensure staff undertake updated training in respect of first aid/CPR and records are retained in the home. 30/03/06 25 OP32 10(1) 12(1) 30/03/06 26 OP33 24 30/07/06 27 OP36 18(2) 30/04/06 28. OP38 13(5) 30/03/06 29. OP38 16(2j) 30/04/06 30. OP38 13(4) 30/04/06 Ardenlea Court DS0000004566.V281377.R01.S.doc Version 5.1 Page 31 31. OP38 13(4) The registered person must undertake a regular audit of falls and implement appropriate strategies for the reduction/prevention of falls. Timescale of 15/11/05 not met. 15/02/06 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. 2. 3 Refer to Standard OP15 OP16 OP35 Good Practice Recommendations It is recommended that menus be changed on a seasonal basis and the menus. (Carried forward) It is recommended that the complaints procedure is placed in a more prominent position in the reception area. (Carried forward) The money used for purchase of food and garden equipment is refunded to the residents fund. (Carried forward) Ardenlea Court DS0000004566.V281377.R01.S.doc Version 5.1 Page 32 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Ardenlea Court DS0000004566.V281377.R01.S.doc Version 5.1 Page 33 - 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. 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