Inspection on 20/09/05 for Ardenlea Court

This inspection was carried out on 20th September 2005.

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

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

Other inspections for this house

Ardenlea Court 30/07/08

Ardenlea Court 05/06/07

Ardenlea Court 05/07/06

Ardenlea Court 01/02/06

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 19-21 lode Lane Solihull West Midlands B91 2AF Lead Inspector Ann Farrell Announced 20 September 2005 th 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 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 E54 S4566 ArdenleaCourt V244262 200905 AI stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Ardenlea Court Address 19-21 Lode Lane , Solihull , West midlands B91 2AF Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 011 771 7773 0121 771 2235 BUPA Care Homes (BNH) Care Home 63 Category(ies) of Physical Disability (63) - Old Age (63) registration, with number Terminally Ill (5) of places Ardenlea Court E54 S4566 ArdenleaCourt V244262 200905 AI stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. May provide accommodation, nursing, and personal care for up to 5 people requiring palliative care. 2. 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. 3. 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. 4. Rehabilitation facilities and equipment must not impinge upon or reduce the communal space available to non-intermediate care service users. Date of last inspection 15th February 2005 Brief Description of the Service: The Registered owners of Ardenlea Court are BUPA Care Homes, a large, well established private company whose head office is in Leeds. Ardenlea Court is a purpose built Care Home providing 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. Ardenlea Court E54 S4566 ArdenleaCourt V244262 200905 AI stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection was conducted over one and a half days commencing at 8.30 am on 20th September 2005. At the time of the inspection a complaint had been forwarded to the Commission, which was investigated at the time of inspection. This was the first statutory inspection for 2005/2006. The manager was present for the inspection. During the inspection process the inspectors toured the home, sampled residents files and other documentation. The manager, four members of staff, approximately sixteen residents and two relatives were spoken to. The Commission also received nine written comment cards from residents, relatives and a health professional. What the service does well: What has improved since the last inspection? There has been an improvement in the activities and the home employs an activities co-ordinator for twenty hours per week. Keys are now available for resident’s bedroom doors and they are being consulted as to whether they would like one. Ardenlea Court E54 S4566 ArdenleaCourt V244262 200905 AI stage 4.doc Version 1.40 Page 6 The manager has commenced a record of informal complaints. She has also undertaken some risk assessments and replaced some of the bed safety rails, which were identified at the last inspection. There has been some staff training in respect of vulnerable adults procedures, manual handling and basic food hygiene. 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. Ardenlea Court E54 S4566 ArdenleaCourt V244262 200905 AI stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Ardenlea Court E54 S4566 ArdenleaCourt V244262 200905 AI stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3,4,5,6 The home has information available for prospective residents enabling them to make a decision about entering the home. Assessments fail to provide sufficient information to staff in order to facilitate them in meeting all resident’s care requirements. EVIDENCE: A service user guide is available in resident’s rooms and on discussion with a resident and family who had recently been admitted they stated they were not given any written information before admission. It is recommended that copies be made available to residents and their families before admission. 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 residents, enabling them to return home. Ardenlea Court E54 S4566 ArdenleaCourt V244262 200905 AI stage 4.doc Version 1.40 Page 9 The majority of long term residents are accommodated on the first floor. Staff utilise the assessment from social workers and also undertake a pre- admission 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 and the manual handling assessment did not indicate how residents should be handled if they had a fall on the floor. 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. There was no evidence of training in this area, which was identified at the time of the last inspection. There is one active and one passive hoist on each floor. On discussion with some residents, who required the hoist, they stated they had to wait as the hoists were in use. The pre-inspection questionnaire indicated there were nineteen residents who require two or more staff to undertake their care. The home will need to undertake a review of the equipment used for manual handling and ensure there is sufficient available to meet resident’s needs. Ardenlea Court E54 S4566 ArdenleaCourt V244262 200905 AI stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10,11 There are systems in place to meet resident’s health needs, but the lack of comprehensive records cannot guarantee consistency of care given to residents. Feedback and observation indicated that resident’s needs were not being fully 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 with inaccurate directions in respect of the care required. Some areas had not been individualised and some actually referred to assessing resident’s needs when their needs should have been fully assessed before a care plan is written up. In addition, some areas of care had not been included in the plan and it was very difficult to track the care provided to residents. Although evaluations had generally been undertaken monthly they were not descriptive and contained statements such as “care as plan” and they had not been updated when changes were noted. There was evidence of risk assessments, but some had not been updated or individualised; the daily records lacked detail and evidence of follow up was not consistently recorded. Ardenlea Court E54 S4566 ArdenleaCourt V244262 200905 AI stage 4.doc Version 1.40 Page 11 All residents are registered with a local G.P. and doctors from one surgery who visits the home every week and in between if required. Staff liaise with health professionals from the multidisciplinary team as required. They have recently secured the services of a chiropodist and there was evidence of visits by dentists and opticians. The staff maintain a separate record of health professionals visits, but the outcome of the G.P.’s visits are not consistently recorded. This will need to be addressed in order to determine if areas of concern have been followed up. On inspection it was noted that fluid balance charts were not being completed to indicate the amount of fluids taken by a resident. The syringe used with PEG feeds was not stored appropriately between uses, there was no oral care equipment in a room where a resident was very ill and care plans stated oral care should be given daily, which is not appropriate to maintain oral hygiene of a resident who is not eating. It was noted that a number of residents did not have access to call bells and lounges were not supervised. Records indicate that there are a large number of residents having falls. On discussion with residents issues were raised about some staffs approach, attitude and willingness to undertake tasks. Some comments were also made about the time taken to answer call bells and the lack of access to call bells and drinks. There were also comments about some staff who were very good and it was stated that one member of staff was going in on her day off to give a resident a bath. Other staff were reported as not being competent in using some of the equipment It was noted that some staff had not undertaken updated training in respect of areas such and manual handling. Some of the issues raised by residents could be linked to the lack of staff training and inadequate staffing levels. These areas need to be fully explored by the management and immediate action taken to address the issues. The home receives medication regularly and on the day of inspection they had commenced a new months prescription. The system was, therefore, not fully inspected. They had a suitable system for receiving, storing and destroying any medication that was not used. 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 E54 S4566 ArdenleaCourt V244262 200905 AI stage 4.doc Version 1.40 Page 12 All bedrooms have locks to doors and many have lockable facilities. Rooms have telephone points and portable trolley telephones are available. The inspector was informed that the telephone was not working and a compliant was made, but they had to resort to buying a mobile telephone in order to make calls. The manager has responded by saying that the telephone was reported, but the problem was such that it took three visits from the engineer to rectify the problem. Residents were informed that they could use the home’s telephone if they wished free of charge. Ardenlea Court E54 S4566 ArdenleaCourt V244262 200905 AI stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15 There have been improvements in respect of social activities, but this needs further development. Menus provided a choice of meals, but the current arrangements, choice and quality of meals were not meeting resident’s needs fully. 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. Visiting is flexible and feedback from relatives indicated that they can visit at any time and are made welcome by staff. The home has employed staff to undertake the role of activities co-ordinators for twenty hours per week and at the time of inspection one member of staff was on duty. Feedback from residents was very mixed with some stating they were happy with activities, but some felt they were only suitable some of the time. On inspection of resident’s records there was no evidence that an assessment in respect of residents interests or past hobbies had been undertaken and there was little evidence of activities occurring. It was noted that some residents were watching television, listening to the radio or talking to each other. It was stated that there had been an activity potting plants and a fish and chip supper. There was also a notice about a fete, which is held each year to raise funds for residents. The manager stated that they were hoping to increase the hours worked by the activities co-ordinator. Ardenlea Court E54 S4566 ArdenleaCourt V244262 200905 AI stage 4.doc Version 1.40 Page 14 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. There is a four-week rotating menu that indicated a variety of food. On discussion with the cook it was stated that they had been in place for five years and some additions had been made to them over that time. It is recommended that the menus are reviewed in consultation with the residents and they are changed on a seasonal basis. Feedback from residents was very varied in respect of the meals. A minority were happy with the food. Many others indicated that the meals were variable, some stated the tea time menu was poor, another stated they liked some of the choices, others stated the meals were cold, another stated they did not like the food. It was stated that drinks and snacks are available between meals, but it was noted that residents were given mid morning drinks and were not offered any biscuits or alternative and it appears that supper is not routinely offered to residents. This means that residents are not offered anything to eat until breakfast the next morning, which is over 12 hours. The manager must ensure that all residents are offered supper in the evening. Tables were laid appropriately for lunch, fresh fruit was available and menus were on the table indicating the menu of the day. It was a very social occasion with residents talking to each other. Staff were available and responded to residents requests appropriately. However, residents on one table were not served meals together. It is recommended that this practice be reviewed. One resident stated it was the hottest meal he had received since he had been in the home and feedback from another resident indicated that it could be very noisy from the kitchen. These areas will also need to be reviewed by the manager and addressed. In addition to the menu of the day a flip chart is displayed in the reception areas with the menu. Also a two-week menu was displayed on the wall in the dining room, which did not always correspond with the menu of the day and this may be confusing to some residents. Ardenlea Court E54 S4566 ArdenleaCourt V244262 200905 AI stage 4.doc Version 1.40 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 The procedures in place for complaints fail to fully address concerns raised and, therefore, may not fully protect residents. 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. The home indicated that they had received three complaints, of which two had not been upheld and one was under investigation. The Commission had received two complaints at the time of visiting. One was in respect of the lack of gloves for use by staff, which was passed to the organisation to investigate. There was no evidence of this at the time of inspection. The complaint that was being investigated on the day of inspection covered a number of areas including staff attitudes, the time taken for staff to attend, meals, routines, laundry and the loss of a sum of money. Since the last inspection the home has commenced recording informal complaints and there was evidence of this. However, it appears that all complaints had not been recorded. As identified earlier in the report a resident stated they had complained about the telephone being out of order and this Ardenlea Court E54 S4566 ArdenleaCourt V244262 200905 AI stage 4.doc Version 1.40 Page 16 had not been recorded. The manager must ensure there are suitable systems in place for addressing all complaints. A number of staff have undertaken training in respect of vulnerable adult procedures since the time of the last inspection. Ardenlea Court E54 S4566 ArdenleaCourt V244262 200905 AI stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for 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 E54 S4566 ArdenleaCourt V244262 200905 AI stage 4.doc Version 1.40 Page 18 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 on each floor and two lounges, which are pleasantly decorated and furnished. In addition, there is seating in the reception area. 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 decoration and the manager stated they would be addressing these areas in the coming year. All areas inspected with the exception of one were cleaned to a good standard. The carpet in one room was sticky under foot and there was an odour in the room. On the ground floor it was noted that the covering of one armchair was damaged and the extractor fan in one bathroom was not working. 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. 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. A large number of bedroom doors were propped open. This a fire risk and the manger had undertaken some risk assessments and she stated that appropriate closures are to be fitted to bedroom doors next year, which would allow doors to close automatically when the fire alarm rings. The main kitchen is situated on the ground floor and was well maintained. It was noted that some sauces had been opened and not labelled, the temperature of one fridge was not recorded plus a new frying pan and saucepan were required. Laundry facilities and sluice facilities are appropriately sited and the manager is in the process of addressing the requirement in respect of appropriate hand washing facilities in the laundry. Ardenlea Court E54 S4566 ArdenleaCourt V244262 200905 AI stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 The procedures for the recruitment of staff are not sufficiently robust to demonstrate residents living in the home are adequately protected. The number of staff on duty during the day is not currently meeting the needs of residents. EVIDENCE: The ground and first floor are staffed separately due to the difference in client group. The first floor has 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. Since the time of the last inspection staffing levels have been increased by one carer to bring it inline with staffing levels of one member of staff to five residents. Inspection of the rota indicated that there are times during the day when numbers of staff available to meet resident’s needs is inadequate. 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 were times when the staffing ratio of one to five was not being maintained. In addition, the manger needs to review the allocation of some shifts to staff, which results in staff working without adequate rest periods between shifts. The home has a number of residents who require two staff to provide care and some with high dependency needs. In addition, there are a number of residents experiencing falls. The manager was advised that staffing levels Ardenlea Court E54 S4566 ArdenleaCourt V244262 200905 AI stage 4.doc Version 1.40 Page 20 need to be reviewed and increased on the first floor to meet the resident’s needs. There needs to be a review of the working arrangements of staff. It was stated that induction training is given to new staff and they are supernummary for two days. Records were not seen to demonstrate this occurring. The information from the manager indicates that only seven care staff have completed NVQ training. A small number of staff files were examined and it was found that they did not contain evidence of proof of identity, right to work in this country and CRB checks had been used from other organisations indicating that POVA checks had not been undertaken in respect of staff. Ardenlea Court E54 S4566 ArdenleaCourt V244262 200905 AI stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,35,38 The maintenance aspects of the home were well managed. Although there has been some training since the last inspection this has not been provided to all staff in order to equip then with the basic skills and knowledge to meet resident’s needs. EVIDENCE: The manager has been in post for approximately nine months, but has not applied to the Commission for registration to date. The responsible individual will need to ensure an application form is completed and forwarded to the Commission to enable the process of registration to commence. A sample of maintenance/servicing files were inspected and were found to be satisfactory with all servicing up to date. The home holds money on behalf of residents; receipts and records were in place and the system appeared to be robust. It was noted that money was used from the residents fund for items such as plants, a gazebo and a fish and chip supper. However, such items should be funded by the home. This was discussed with the manager for Ardenlea Court E54 S4566 ArdenleaCourt V244262 200905 AI stage 4.doc Version 1.40 Page 22 future reference and it is recommended that this money be refunded to the resident’s fund. Inspection of staff training records indicated that some staff had undertaken manual handling and basic food hygiene training, but a number of staff had not undertaken all the mandatory training in respect of fire prevention, fire drills, basic food hygiene, manual handling, infection control or first aid. It was stated that one member of staff is now a manual handling trainer and has commenced this training with staff. The manager was advised that time must be given to staff to provide the training and also to attend training and maintain up to date records. 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. Ardenlea Court E54 S4566 ArdenleaCourt V244262 200905 AI stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 2 2 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 x 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 2 3 3 3 3 2 3 2 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 Standard No 16 17 18 Score 2 x 2 2 x x x 2 x x 2 Ardenlea Court E54 S4566 ArdenleaCourt V244262 200905 AI stage 4.doc Version 1.40 Page 24 yes Are there any outstanding requirements from the last inspection? 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 Requirement Timescale for action 15/11/05 2. OP4 18(1) 3. OP4 23(2)(n) 4. OP7 15 The registered person must: Ensure a comprehensive assessment of all residents is undertaken upon admission to the home. Review the maual handling assessment and update to include details of the action to be taken if a resident falls on the floor. The registered person must 30/2/06 ensure all staff undertake training in respect of caring for residnets with dementia commensurate with their position in the home. Timescale of 30/7/05 not met. The registered person must 15/11/05 undertake an audit of manual handling equipment and ensure there is sufficient equipment available to meet residents needs. 30/11/05 The registered person must ensure all nursing staff complete a comprehensive care plan outlining how residents needs are to be met following assessment. The care plans must include all areas of need, be comprehensively reviewed Version 1.40 Ardenlea Court E54 S4566 ArdenleaCourt V244262 200905 AI stage 4.doc Page 25 5. 6. OP8 OP8 7. OP10 8. OP11 9. OP12 10. OP8 11. OP15 each month and updated when there are any changes. Timescale of 30/5/05 not met. 17(1)(a) The registered person must ensure records indciate the outcome of doctors visits. 12(1)(2) The registered person must (3)(4) address all the issues outlined in the body of report in respect of positioning and answering call bells, oral hygiene, completion of fluid charts, staff approach etc. 12(4) The registered person must (16)(2)(a) ensure the telephone for residents use is in working order at all times. 18(1) The registered person must ensure all staff receive training in respect of palliative care commensurate with their position in the home and records are retained. 16(2)(m) The registered person must (n) ensure an assesment is undertaken in respect of residents past interests and hobbies and a plan of activites drawn up (individual or group) implemented and records are retained in the home. Timescale of 20/1/04 not met 13(4) The registered person must review all the bed safety rails on residents beds and ensure they are of sufficient height to maintain residents safety. 16(2)(i) The registered person should undertake a review of the meals/mealtimes to include: The menus and choices available in consultation with residents. The serving of meals. Arrangements for snacks and supper. The temperature of meals when served to residents. The noise from the kitchen. E54 S4566 ArdenleaCourt V244262 200905 AI stage 4.doc 30/10/05 30/10/05 30/10/05 30/1/06 30/11/05 30/10/05 30/10/05 Ardenlea Court Version 1.40 Page 26 12. OP16 22 13. OP18 13(6) 14. OP19 23(4) 15. OP19 16(2)(j) 16. 17. 18. OP19 OP24 OP24 16(2)(g) 23(2)(d) 23(2)(m) 19. 20. 21. 22. OP24 OP26 OP26 OP26 16(2)(c 23(2)(d) 16(2)(k) 23(2)(p) 23. OP26 13(3) The registered person must ensure a record of all complaints are retained in the home indicating the investigation, action taken, outcome and resolution. The registered person must ensure that all remaining staff undertake training in respect of the vulnerable adult procedures and the action to take in the event of an allegation. The registered person must provide a plan of action to the Commission indicating when bedroom doors will be linked into the fire alarm system. The registered person must ensure all sauces are dated when opened and all fridge temperatures are recorded. The registered person must replace saucpan and frying pan in the main kitchen. The registered person must audit the home and re-decorate as required. The registered person must ensure all bedrooms are provided with lockable facilities, keys are available and residents are consulted about having a key. The registered person must replace any worn/damaged furnishings. The registered person must ensure all carpets are kept clean. The registered person must ensure all areas are kept odour free. The registered person must undertake an audit of all extractor fans and ensure they are in working order. The registered person must ensure facilites are available in 30/10/05 30/11/05 30/10/05 30/10/05 30/10/05 30/2/06 30/12/05 30/12/05 30/10/05 30/10/05 15/11/05 30/10/05 Ardenlea Court E54 S4566 ArdenleaCourt V244262 200905 AI stage 4.doc Version 1.40 Page 27 24. 27 18(1) 12(1) 25. 26. OP28 OP29 18(1) 19 27. OP29 17(2) 28. OP30 18(1) 29. OP31 8 30. OP38 23(4)(d) (e) 31. OP38 13(5) 32. OP38 13(3) the laundry room for staff to clean their hands. 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 depenency. The registered person must ensure at least 50 of care staff are trained to NVQ level 2. The registered person must ensure a robust recruitment procedure and POVA checks are undertaken before staff commence employment in the home. The registerd person must ensure all staff files include proof of identity and right to work in the country. The registered person must ensure all new staff undertake induction training and records are retained in the home. The responsible individual must ensure an applicaiton form is forwarded to the Commission for the registration of the manger. The registered person must ensure all staff undertake fire training and drills at least twice a year and records must be retained in the home. Timescale of 30/5/05 not met. The registered person must ensure all staff undertake 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 infection control and records are retained in the home. Timescale of 30/7/05 not met. 30/10/05 30/3/06 30/10/05 30/10/05 30/11/05 30/10/05 30/11/05 30/11/05 30/12/05 Ardenlea Court E54 S4566 ArdenleaCourt V244262 200905 AI stage 4.doc Version 1.40 Page 28 33. OP38 16(2)(j) 34. 35. OP38 OP38 13(4) 13(4) The registered person must ensure all staff undertake trianing in respect of basic food hygiene. The registered person must ensure there is at least one first aider on each shift. The registered person must undertake a regular audit of falls and implement appropriate strategies for the reduction/prevention of falls. 30/1/06 30/12/05 15/11/05 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 OP1 Good Practice Recommendations It is recommended that a copy of the service user guide is made available to prospective residents and their families to enable them to make an infomed choice before moving into the home. It is recommended that staff receive training in respect of customer care. It is recommended that menues are changed on a seasonal basis and the menus displayed on dining room walls are removed. It is recommended that the complaints procedure is placed in a more prominent positon in the reception area and the procedure is discussed with residents at the residents meeting. The money used for purchase of food and garden equipment is refunded to the residents fund. 2. 3. 4. OP10 OP15 OP16 5. OP35 Ardenlea Court E54 S4566 ArdenleaCourt V244262 200905 AI stage 4.doc Version 1.40 Page 29 Commission for Social Care Inspection Birmingham & Solihull Local Offic 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 E54 S4566 ArdenleaCourt V244262 200905 AI stage 4.doc Version 1.40 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!