Inspection on 05/07/06 for Ardenlea Court

This inspection was carried out on 5th July 2006.

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

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

Other inspections for this house

Ardenlea Court 30/07/08

Ardenlea Court 05/06/07

Ardenlea Court 01/02/06

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 Jane Walton Unannounced Inspection 09:30 5th July 2006 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.V300346.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. Ardenlea Court DS0000004566.V300346.R02.S.doc Version 5.2 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 Mrs Kim Elizabeth Brown 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.V300346.R02.S.doc Version 5.2 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. 1st February 2006 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 fifty five residents over the age of 65, who are frail elderly and/or physically disabled. Of the fifty five 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.V300346.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced Key Inspection took place over 2 days in July 2006. This was the first inspection for the Inspection year 2006/07. There were 52 residents in the home and the inspector was able to speak to 11 of them, and 5 of their relatives and other visitors to the home. The manager was present throughout the inspection process. 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. Discussion took place with 8 members of staff and a GP who was visiting the home. What the service does well: What has improved since the last inspection? Ardenlea Court DS0000004566.V300346.R02.S.doc Version 5.2 Page 6 All prospective residents are provided with a Service Users Guide at the time of the pre admission assessment. Additional moving and handling equipment has been provided as appropriate. Two registered nurses have completed a course in Dementia care, and will cascade the training to the remaining staff. Six registered nurses have been enrolled to undertake a course in Palliative Care. Bed rail audits have been completed. The work of converting 2 bedrooms into 1 lounge has now been completed. The homes’ recruitment procedure has improved. A programme of training is being undertaken, although not all staff have been recorded as having had up to date moving and handling. All bedroom doors are now linked to the fire alarm system, and will close automatically in the event of the fire alarm sounding. 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 DS0000004566.V300346.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 Ardenlea Court DS0000004566.V300346.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4, 5 & 6 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. All the practices and procedures surrounding the admission of new residents were adequate and appropriate to ensure that the home is able to fully meet their needs. Prospective residents are provided with sufficient information to enable them to make an informed choice about living in the home. EVIDENCE: There is a Statement of Purpose and a Service Users Guide that meet the required standard. A copy of the Service Users Guide is provided in each residents’ bedroom, and the manager takes a copy for prospective residents when she carries out their pre admission assessment. 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. Ardenlea Court DS0000004566.V300346.R02.S.doc Version 5.2 Page 9 It was evidenced 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. Six of the registered nurses are enrolled to undertake a Palliative care course in September and October 2006, to better enable them to met residents’ needs. Conversations with visitors indicated that they are made welcome, and are able to look around the home prior to their relative being admitted. 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. The majority of long-term residents are accommodated on the first floor. Ardenlea Court DS0000004566.V300346.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11 Quality in this outcome area is poor. The judgement has been made using available evidence including a visit to this service. Care planning systems need to be developed further, and audit findings acted upon, to ensure all residents needs are met and there is adequate supervision at all times. The systems for medicine management require improvement in order to ensure residents medication needs are met. EVIDENCE: Staff had drawn up care plans for all residents and a sample were inspected. Since the last inspection regular audits of the care plans has been undertaken and the documentation was examined. The findings of the auditor were that some of the criteria, for example, risk assessments, progress records and reviews of the plan were not consistently completed. Of the sample that were inspected, all were found to have deficiencies. The plans were complicated and the management of needs was not always easy to identify. Risk assessments had been carried out, but were not always dated, and were inconsistent. The plans were not always signed and there was no evidence that the residents had been actively involved in it’s production. Ardenlea Court DS0000004566.V300346.R02.S.doc Version 5.2 Page 11 Although one resident was noted to suffer continence issues, a continence assessment had not been completed. It was not always obvious that the care plans had been reviewed regularly. Some residents have many falls, and it was recommended that the manager carry out a falls audit, and implement plans for falls prevention, and refer affected residents to a falls clinic. Separate wound monitoring records are kept and evidence was seen that a Tissue Viability Nurse’s input had been sought, and the regime was documented. Descriptions of wound healing progress are kept, but it was recommended that staff kept tracings or photographic evidence of the progress. 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. An audit of the medication management in the home was carried out. At the time of the inspection the weather was very hot, and the temperature in the room on the ground floor where the medicines are stored was recorded as 30 degrees centigrade, which is far too hot and could affect the efficacy of the medicines. The visiting GP also noted this. The manager stated that there were steps being taken to provide an air conditioning unit, but short term, alternative management would have to be found. There was a dedicated drugs fridge, for which the minimum/maximum temperatures are recorded daily, and were within parameters. The Controlled Drugs (CD) cupboard meets requirements. The home is supplied by a local pharmacy and utilises a Monitored Dosage System(MDS) on the first floor, and mainly individually labelled boxed medicines on the ground floor. This is due to the short stay nature of the Intermediate care residents on the ground floor. On both floors the medicine management was found to be poor, with discrepancies in tablet counts for all Medicine Administration Record (MAR) charts examined.. 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. Eye drops that should have been kept refrigerated were found on the trolley, with excessively high ambient temperatures. Ardenlea Court DS0000004566.V300346.R02.S.doc Version 5.2 Page 12 The home is registered to care for residents for reason of palliative care, and staff have been enrolled to undertake training in this area. The family of one of the residents commented that “The staff have been wonderful to us all. They look after us really well and are very supportive”. All bedrooms have locks to doors and many have lockable facilities. Rooms have telephone points and portable trolley telephones are available. All bedrooms are singles with en suite facilities. Ardenlea Court DS0000004566.V300346.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, & 15 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. Residents are supported to maintain social activity, contact and have their recreational needs met. Meals and the mealtimes meet the needs of residents, and the selection of food available helps to promote the residents well-being. 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. One resident was seen to be waiting for her transport to the day centre, that she visits regularly. The resident stated “ I like going, and I do my tapestry whilst I’m there”. The home employs an activities organiser for 10 hours per week, and a further post is advertised for 20 hours per week. A notice of planned activities was displayed, with a forthcoming summer party, and a trip to the Nature Centre. The organiser has several years of experience but has had no formal training. She has, however, undertaken some training to carry out therapeutic massage for hands and knees. Ardenlea Court DS0000004566.V300346.R02.S.doc Version 5.2 Page 14 Records are kept, and were evidenced, of the activities that are undertaken by the individual residents. The majority of the organisers time is spent with the long term residents on the first floor. On the ground floor, several of the Intermediate care residents said that they thought there was not enough activities for them to do. They are welcome to join in with the first floor residents if they wish to, however, those spoken to were not aware of this. Staff stated that mornings are spent with the Physiotherapists and OT’s working on their rehabilitation programmes. Residents bedrooms on the first floor contained many personal possessions, that they are encouraged to bring in, and were very homely and comfortable. Due to the short stay nature of the ground floor, the bedrooms, although very comfortable, lacked the personal items. 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. The daily menu was on display, and the meal served corresponded to what was displayed for that day. The inspector joined the residents for lunch in the ground floor dining room. Tables were laid with cloths, mats, napkins, cutlery and condiments. A menu was on each table. The meal was hot, well presented and very tasty. Residents commented that the food is generally very good, homemade, and there is always a choice. A cooked breakfast can be eaten every day if the residents’ want to. Tea is provided at 5.30 pm offering a selection of sandwiches, homemade soup and a hot dish, and sandwiches are available in the evening. However, some residents were not aware that this was the case, and were under the impression that there was nothing available from tea time to the following mornings breakfast. One resident stated that they did not like to ask the staff for anything to eat at night as they were very busy. This was discussed with the manager and the kitchen staff, and a possible solution is to take the trays of sandwiches around on the evening drinks trolley. Special diets are provided, and discussion with the kitchen staff indicated they were aware of who required them. Staff were observed in attendance during the meals and demonstrated a good knowledge of peoples likes and dislikes. One member of staff assisted a resident with their meal in a very patient and courteous manner. No one was rushed to finish their meal. Ardenlea Court DS0000004566.V300346.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, & 18 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure that is accessible to residents and visitors so that they are aware of how to make a complaint ensuring the promotion of protection matters. 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, and has been moved to a more prominent place. The home has a separate adult protection procedure, which is a corporate document and is to be used in conjunction with the local guidance. Staff have received training in Adult Protection matters, and staff spoken to responded appropriately to questions about abuse. Ardenlea Court DS0000004566.V300346.R02.S.doc Version 5.2 Page 16 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 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. The décor and furnishings are of a good standard and provide a homely and pleasant environment for residents to live in. EVIDENCE: Ardenlea Court DS0000004566.V300346.R02.S.doc Version 5.2 Page 17 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 residents are consulted as to whether they wish to have a key. Bedrooms have lockable facilities for valuables or medication. A number of bedrooms had been personalised by residents and many were decorated to a good standard. 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. 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. All bedrooms, on both the ground floor and first floor have been fitted with automatic closures in the event of a fire. These have been linked into the fire alarm system so that residents may have their doors open if they wish. The main kitchen is situated on the ground floor and was well maintained. Requirements from the last inspection have all been carried out. The door to the satellite kitchen on the first floor was not locked when unattended and may pose a risk to residents. This was also the situation at the last inspection. Ardenlea Court DS0000004566.V300346.R02.S.doc Version 5.2 Page 18 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 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. 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 were 26 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, and the manager confirmed that when dependency levels increase the staffing numbers are reviewed and increased if deemed necessary. There is generally 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. Ardenlea Court DS0000004566.V300346.R02.S.doc Version 5.2 Page 19 The ground floor has 5 long term residents and 18 Intermediate care beds. The PCT has a base in the home and 2 nurses are on duty, together with physiotherapists, OT’s, and a therapy assistant. There appeared to be a good working relationship between the PCT and home staff. The home employs 30 care staff and 6 of these are trained to NVQ2, and a further 6 are currently undertaking the course. However, this is below the required number, and steps need to be taken to ensure that a greater number are trained to this level in order to meet the standard. A sample of staff files was examined and it appeared that a robust recruitment procedure is utilised by the manager. However, one file was found to be missing the trained nurse PIN confirmation check from the NMC. This was faxed to the CSCI immediately following the inspection. The manager must also ensure that repeat CRB checks are carried out if the 3 year period has expired since the last one. Evidence was seen that the most recently employed staff had undertaken Induction training. A training matrix is currently being compiled to identify staff training needs. A separate file is maintained containing the individual training records for all staff members. The manager needs to ensure that all staff have received up to date statutory training in moving and handling. A range of training is provided including Wound Care, Venepuncture, IV therapy, Adult Protection, Dementia awareness and a forthcoming course in Palliative Care has been booked. Ardenlea Court DS0000004566.V300346.R02.S.doc Version 5.2 Page 20 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, 33,35, 36, & 38 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. The maintenance aspects of the home are well managed. Staff supervision, and quality assurance systems need to be reviewed and developed to ensure the home addresses shortfalls, develops and continues with a commitment to residents. EVIDENCE: The Registered manager of the home is an RGN level 1 nurse with many years experience in the care environment. She is currently undertaking her Registered Managers Award and is due to complete in November 2006. Since the last inspection staff meetings and residents meetings have been held, and the minutes of these meetings were seen. Ardenlea Court DS0000004566.V300346.R02.S.doc Version 5.2 Page 21 The staff meetings are not always held on a regular basis. BUPA the owners of the home carry out an annual QA questionnaire, that is a corporate document, in October each year, for each of the homes in the group. The questionnaire was stated to include local information from each home. However, the document is very cumbersome and lengthy, and it was recommended that a summary of the findings be made available that was more “user friendly”. The home operates a robust system for the management of residents’ personal expenditures. Regular documented supervisions are not currently carried out. It was stated that the trained nurses, who have been trained by the manager, will carry out supervisions for the care staff. Records of service, tests and maintenance in respect of health and safety for utilities, appliances and equipment such as electricity, fire and hoists are well maintained. There are a range of risk assessments for the premises, however, they require updating. The fire risk assessment had been completed and updated on 30/1/06. There is a COSHH file and relevant data sheets are available to staff. Ardenlea Court DS0000004566.V300346.R02.S.doc Version 5.2 Page 22 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 3 x 2 2 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 1 x 3 Ardenlea Court DS0000004566.V300346.R02.S.doc Version 5.2 Page 23 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 OP3 Regulation 14 Requirement The registered manager must: Ensure a comprehensive assessment of all residents is undertaken upon admission to the home, and that staff have had the appropriate training to meet the needs of residents requiring palliative care. The registered must ensure all staff undertake training in respect of caring for residents with a dementia commensurate with their position in the home. Timescale of 30/7/05 not met. The registered manager 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 DS0000004566.V300346.R02.S.doc Timescale for action 30/08/06 2. OP4 18(1) 31/10/06 3. OP7 15 30/08/06 Ardenlea Court Version 5.2 Page 24 ensure care plans are implemented with appropriate interventions e.g. where a resident has a number of falls. 4. OP9 13(2) The registered manager must ensure: 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. Appropriate action must be taken when discrepancies are found when carrying out staff drug audits. 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. Any medicines requiring refrigeration must be kept in the drugs fridge as per the manufacturers instructions. Suitable arrangements must be made to ensure that the ambient temperature of the medication storage room does not rise above 25 degrees centigrade. The registered manager must ensure all staff receive training in respect of palliative care commensurate with their position in the home and records are retained. The registered manager must ensure: Arrangements are in place to DS0000004566.V300346.R02.S.doc 01/08/06 5. OP11 18(1) 30/10/06 6. OP15 16(2i) 06/07/06 Ardenlea Court Version 5.2 Page 25 ensure that residents are aware that supper is available on a daily basis. 7. OP19 13(4) The registered manager must ensure the satellite kitchen on the first floor is kept locked when not attended by staff. The registered manager 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 manager must ensure at least 50 of care staff are trained to NVQ level 2. The registered manager needs to ensure that all staff have received up to date statutory training in moving and handling, and that it is documented. The registered manager must ensure that the quality assurance process in the home, based on seeking feedback from all stakeholders and is in an accessible format. 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. 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. DS0000004566.V300346.R02.S.doc 06/07/06 8. OP27 18(1) 12(1) 15/07/06 9. OP28 18(1) 31/12/06 10. OP30 18(1)(c)(i ) 31/08/06 11. OP33 24 30/07/06 12. OP36 18(2) 30/10/06 13. OP38 13(4) 15/09/06 Ardenlea Court Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ardenlea Court DS0000004566.V300346.R02.S.doc Version 5.2 Page 27 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.V300346.R02.S.doc Version 5.2 Page 28 - 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!