Inspection on 13/10/05 for Ardenlea Grove

This inspection was carried out on 13th October 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 Grove 13/10/08

Ardenlea Grove 24/10/07

Ardenlea Grove 14/06/06

Ardenlea Grove 14/03/06

Ardenlea Grove 17/02/05

Ardenlea Grove 29/09/04

Ardenlea Grove 23/02/04

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

CARE HOMES FOR OLDER PEOPLE Ardenlea Grove 19-21 Lode Lane Solihull West Midlands B91 2AF Lead Inspector Amanda Lyndon Announced 13 October 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 Grove E54 S4528 ArdenleaGrove V258669 131005 AI stage 4.dot Version 1.40 Page 3 SERVICE INFORMATION Name of service Ardenlea Grove Address 19-21 Lode Lane Solihull West Midlands B91 2AF 0121 705 9222 0121 705 9333 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) Bupa Care Ltd Care Home 60 Category(ies) of Old Age - Physical Disability - (60) registration, with number of places Ardenlea Grove E54 S4528 ArdenleaGrove V258669 131005 AI stage 4.dot Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. May provide accommodation, nursing and personal care for one named person (NA) under 65 years of age. 2. May provide accommodation to one named Service User (MH) under the registered age of 65 years Date of last inspection 17 February 2005 Brief Description of the Service: Ardenlea Grove is a purpose built care home with a category of registration for older people requiring general nursing care. Built in 1996/7, the premises are located within a development of retirement homes and flats. Ardenlea Grove stands in its own grounds. It is situated opposite Solihull Hospital on the main thoroughfare from Solihull to the Coventry Road, and is in close proximity to local shops, local transport services and other community amenities. Ten beds are designated for a continuing care contract. The building has three floors and a basement, the latter being used for utility services and staff rooms. The main part of the Home is accessed from the reception area to the ground floor and passenger lift. All bedrooms are offer single accommodation and have an en suite facility including an assisted shower or bath. A garden area is available and easily accessible. A smoking facility for residents is not provided within the internal environment of the Home. Ardenlea Grove E54 S4528 ArdenleaGrove V258669 131005 AI stage 4.dot Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection was undertaken by three Inspectors, including the Pharmacist Inspector when there were fifty two residents living there. The Inspectors were assisted by the General Manager and Acting Manager. Information was gathered from speaking with the residents, visitors and staff, observing the staff perform their duties and examining care, medication and health and safety records. A full tour of the premises was undertaken. Prior to the inspection CSCI received eleven comment cards in respect of the service provided at Ardenlea Grove and these included comments that were both positive and negative in nature. It was pleasing that a number of the negative issues raised had already been addressed by the Acting Manager and remedial action had been undertaken. What the service does well: Residents are generally well supported by the care staff to meet their personal care, health and welfare needs. One visitor said “ I am very happy with the nursing care here, it is very good. My relative is always immaculate, everything is done for her here”. Residents are generally supported in a respectful manner by staff working at the home and this ensures that their dignity and self esteem are maintained. The Home has an open visiting policy and residents are supported by the staff to maintain contact with their family, friends and the community. Residents can exercise their choice over their daily lives and this ensures that their independence and individuality is maintained. One resident said “ It is really lovely here. I can get up any time that I want and have a cup of tea if I want one. I can also go to bed when I want to”. Residents are offered a choice of wholesome and nutritious meals and any special dietary requirements are catered for. One resident said “ The food is lovely here, I get a choice of food and I’m asked the day before what I would like to eat”. Ardenlea Grove provides a generally clean, safe, comfortable and homely environment for residents to live in. One visitor said “ It is always clean when Ardenlea Grove E54 S4528 ArdenleaGrove V258669 131005 AI stage 4.dot Version 1.40 Page 6 we visit here”. Residents’ bedrooms contained many personal items to ensure that they felt comfortable within their surroundings. Agency staff are rarely used at the Home and this ensures that continuity of care is maintained. One relative said “ The care team are efficient, caring and conscientious” One resident said “ The staff are lovely and answer the call bell promptly if I need them”. New staff undertake comprehensive induction training to ensure that they have a basic knowledge of working within their job roles after commencing employment at the Home. Residents are invited to regular group meetings in order to put forward their suggestions about the service provided at Ardenlea Grove. What has improved since the last inspection? What they could do better: Residents must be involved in the agreeing of their care plans in order to ensure that their preferred daily routines are maintained. Appropriate pressure relieving mattresses must be available for all residents deemed to be in need to ensure that their physical health care needs are met. Ardenlea Grove E54 S4528 ArdenleaGrove V258669 131005 AI stage 4.dot Version 1.40 Page 7 Staff must ensure that the nurse call bell is positioned within the easy reach of residents so that help can be summoned when required. Doors to residents’ bedrooms must be fitted with appropriate locks to give residents the option of keeping their bedrooms secure. Activities must be provided for residents with dementia care needs and for those residents that are either nursed in bed or choose to remain in their bedrooms. The previously agreed staffing levels must be maintained to ensure that residents are supported by an adequate number of staff. The home must ensure that all necessary pre recruitment checks are undertaken in respect of prospective staff members to ensure that residents are afforded full protection. Further training in respect of health and safety issues and other training relevant to the care needs of the residents needs to be provided. 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 Grove E54 S4528 ArdenleaGrove V258669 131005 AI stage 2.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Ardenlea Grove E54 S4528 ArdenleaGrove V258669 131005 AI stage 2.doc Version 1.40 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 standard(s) 1, 2, 3, 4 & 5 Prospective residents have the majority of relevant information about Ardenlea Grove and this enables them to make a choice about whether they would like to live there. Residents’ care needs are reviewed regularly to ensure that their needs can be best met by living at the Home. EVIDENCE: A comprehensive statement of purpose had been produced and this requires further development to include the information that there is no smoking facility provided for residents within the internal environment of the Home. Assessments of prospective residents care needs are undertaken by senior staff using a comprehensive pre admission assessment document, however letters informing prospective residents and their families that their care needs could be met at the Home were not always written. On admission to the Home, residents are issued with a comprehensive contract of terms and conditions of residency outlining all required information and Ardenlea Grove E54 S4528 ArdenleaGrove V258669 131005 AI stage 2.doc Version 1.40 Page 10 residents come to live at there for a trial period of four weeks. Ardenlea Grove is registered for older people in need of general nursing care, however a number of residents that had lived there for a period of time had additional dementia care needs. Multi disciplinary advice had been sought by the Home’s staff in respect of these residents’ care needs as deemed necessary. Ardenlea Grove E54 S4528 ArdenleaGrove V258669 131005 AI stage 2.doc Version 1.40 Page 11 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 Residents’ health and personal care needs were generally well met, however some poor care practice and documentation in respect of this fails to ensure that the holistic needs of all residents are being met. The systems for medicine management have improved since the last inspection, however needs to be enhanced to ensure residents’ medication needs are met. Residents are generally cared for in a respectful manner by staff working at the Home and this ensures that their dignity and self esteem are maintained. EVIDENCE: Comprehensive assessments are undertaken for all residents on admission to the Home and care plans are derived from these. This included a social history and associated social needs assessment record, and the preferences of individual residents in respect of their daily lives. Care plans were reviewed regularly, however, were not always written and agreed with the involvement of the resident and/or their representative. Comprehensive care plans in respect of wound care, mental health and acute health care needs were in place and there was evidence that these needs were Ardenlea Grove E54 S4528 ArdenleaGrove V258669 131005 AI stage 2.doc Version 1.40 Page 12 monitored appropriately, however care plans were not written for all nursing care needs. Daily reports written by the Registered Nurses were recorded in good detail and in addition to this, a key worker diary was maintained. Individual assessments had been undertaken in respect of nutritional needs, oral health, moving & handling, pressure area care and continence management. Not all assessments included sufficient information or detail of how staff were to provide support to maintain as much independence as possible, consistent with residents wishes. Some issues noted that were brought to the attention of the acting manager included bed safety rails which were too low and poor positioning of a resident during transfer. A resident had been positioned in bed with the nurse call facility out of reach. Residents have the option of retaining their own General practitioner on admission to the Home and have access to other visiting Social and Health Care Professionals, including Chiropodists, Opticians and Nurse Specialists. One visitor said “ I am very happy with the nursing care here, it is very good. My relative is always immaculate, everything is done for her here”. Residents appeared to be well supported to meet their personal hygiene needs and were wearing clothing appropriate for the time of year. The majority of audits undertaken to demonstrate that medicines had been administered as prescribed and recorded accurately were correct. Care needs to be taken to ensure that all the medicines not supplied in a Monitored Dosage System are administered correctly at all times. Staff drug audits to demonstrate good and poor practice for individual nurses were not undertaken. The medication policy must be rewritten to reflect new improved current practice. The medication rooms on all three floors were too hot at the time of the inspection and the stability of the medicines stored within could not be guaranteed. The medicine refrigerator temperatures were also too hot and had not been adjusted to ensure all the medicines were stored correctly. The Acting Manager was keen to improve practice within the home. A programme of fitting suitable privacy locks to residents’ bedrooms was planned. The telephone provided for residents’ use was located in the communal lounge and this does not afford full privacy, however a number of residents had a private telephone line in their bedrooms. Staff were interacting respectfully with residents, however not all staff knocked on residents’ bedroom doors prior to entering. Ardenlea Grove E54 S4528 ArdenleaGrove V258669 131005 AI stage 2.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, 14 & 15 The activities on offer meet the expectations of those residents who are able to participate in group activities but do not meet the needs of all residents living at the Home. Residents are able to maintain contact with family and friends with support from the Home’s staff and are able to exercise choice over their daily lives to ensure that their independence, individuality and needs are maintained. EVIDENCE: An activities organiser is in post at Ardenlea Grove and the programme of activities available is being further developed. There was prize bingo, videos and visiting entertainers on offer, however there were no activities specifically for the residents with dementia care needs and those residents who are nursed in bed or choose to remain in their bedrooms. One resident said “On occasions we have outings here”. One visitor said “There was a sing a long and open day here recently”. A hairdresser visits regularly and Holy Communion was available. Written records of activities provided or details of resident participation are not maintained. There were close links with local schools and churches and a harvest festival was performed by visiting local school children on the day of the inspection. Ardenlea Grove E54 S4528 ArdenleaGrove V258669 131005 AI stage 2.doc Version 1.40 Page 14 The Home has an open visiting policy and one visitor said “ I visit here every day and have a lunch here, I have no complaints”. Another visitor said “ We can visit here at any time and the staff are always friendly and polite to us”. Residents can go out of the Home with their families and friends as they wish. One resident said “ it is really lovely here. I can get up any time that I want and have a cup of tea if I want one. I can also go to bed when I want to”. One staff member said “ We give the residents choice of when they want to get up, it is really up to them”. Prior to the inspection, CSCI received four negative comments about the food provided at the Home, however the menus are currently under review in respect of variety and nutritional content and it is recommended that the residents are involved in the devising of these. Comments were also received that the supper time meals were not always substantial enough and these are also currently under review. On the day of the inspection, one resident said “ The food is lovely here, I get a choice of food and I’m asked the day before what I would like to eat”. Another resident said “ The Chef will always get me something else to eat if I don’t like what is on the menu”. The main meal options of the day were nutritious and well presented and included a starter of soup or fruit juice. Fresh foods were served and any special dietary requirements are catered for. A daily record of food provided for each residents was kept. The dining tables were laid attractively and staff were assisting residents respectfully during their meal. Ardenlea Grove E54 S4528 ArdenleaGrove V258669 131005 AI stage 2.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 complaints procedure is comprehensive and is accessible to residents and their visitors. The adult protection procedures may fail to afford full protection for residents. EVIDENCE: The Organisation had produced a comprehensive complaints procedure and this was on display in a prominent position in the Home, however one visitor stated “ I have no complaints but if I had, I would go to the Management. I am not aware of a complaints procedure but I expect they have one”. There were no new complaints recorded in the complaints log since the previous inspection. The Home had received a number of compliments. The adult protection policy included detail about indicators of abuse and associated information, however it stated that the Home Manager should interview the resident before informing the appropriate external agencies and this is not in accordance with the Department of Health or Local Authority guidelines. The contact details of all relevant local authorities were not included within the policy. Ardenlea Grove E54 S4528 ArdenleaGrove V258669 131005 AI stage 2.doc Version 1.40 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 standard(s) 19, 20, 21, 24, 25 & 26 Ardenlea Grove provides a generally clean, safe, comfortable and homely environment for residents to live in. Aids and adaptations provided ensure that the majority of residents’ needs are met. EVIDENCE: The internal environment of the Home was warm and inviting, furniture, furnishings and fittings throughout were of a good standard and a rolling programme of redecoration was in place. The garden areas had been upgraded and these were found to be both attractive and well maintained. The dining rooms were decorated to a high standard and the chairs were arranged so as to promote social interactions between residents in the lounges. There was appropriate assisted bathing equipment in place to meet the needs of the residents living there. Ardenlea Grove E54 S4528 ArdenleaGrove V258669 131005 AI stage 2.doc Version 1.40 Page 17 Bedrooms were comfortable and contained many personal items to suit residents’ individual tastes. An ongoing programme of replacing beds with an appropriate adjustable nursing type was in place. Lighting was domestic in style and adequate throughout the Home with the exception of within one en suite facility, where this was found to be inadequate. Radiators were of a low surface type and checks on hot water temperatures were undertaken regularly and were within safe limits. The Home was found to be clean and fresh with the exception of a two rooms and this was brought to the attention of the Acting Manager. One visitor said “It is always clean when we visit here”. An effective and hygienic system for the laundry of residents’ personal clothing and bed linen was in place and appropriate sluicing facilities were provided. Ardenlea Grove E54 S4528 ArdenleaGrove V258669 131005 AI stage 2.doc Version 1.40 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 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, 29 & 30 Depleted staffing levels and poor staff recruitment practice fails to afford full protection for residents living at the Home. New staff undertake comprehensive induction training to ensure that they have a basic knowledge of working within their job roles after commencing employment at the Home. EVIDENCE: The staffing rotas identifed that the Home were not always working within previously agreed minimum staffing levels for reasons of staff sickness and staff vacancies. Agency staff were rarely used to cover these shifts. A number of care staff worked an excessive number of hours per week by choice and ways to reduce this must be sought. The Management team provide on call support to the nurse in charge of the shift and this includes evenings and weekends. Kitchen, domestic, laundry, administrative and maintenance staff provide support to the care staff on duty and there were currently vacancies for a Cook and weekend domestic staff. A relative stated “ The care team are efficient, caring and conscientious”. Another relative stated “ The staff have shown great kindness and care”. One staff member said “ I enjoy working here very much, we work in a good team here”. One resident said “The staff are lovely and answer the call bell promptly if I need them”. Ardenlea Grove E54 S4528 ArdenleaGrove V258669 131005 AI stage 2.doc Version 1.40 Page 19 Not all staff files sampled contained satisfactory criminal records clearance or two satisfactory written references. A full audit of staff personnel files must be undertaken. In addition to this, records in respect of the professional registrations of a number of Registered Nurses working at the Home were found to be out of date. Job descriptions and contracts of terms and conditions of employment had been issued to staff members. Staff had received training relevant to their job roles including comprehensive induction training, continence care, care planning, nutrition and NVQ Level 2 and 3 in care. Staff had received training about the protection of vulnerable adults, however there were inconsistencies in the staff’s knowledge about whistle blowing. Staff had not received training in respect of caring for people with dementia care needs. Ardenlea Grove E54 S4528 ArdenleaGrove V258669 131005 AI stage 2.doc Version 1.40 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 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, 32, 35, 36 & 38 The temporary management arrangements in place ensure that the Home is well managed and is run for the benefit of the residents living there and is regularly monitored for quality. Residents are regularly consulted about the service provided at the Home. The health, safety and welfare of residents is protected through maintenance checks of equipment used, however the lack of staff training in respect of some health and safety issues may put residents at risk. EVIDENCE: An experienced Acting Manager had been in post at the Home during the past couple of months, however the future managerial arrangements were unknown at the time of the inspection. Ardenlea Grove E54 S4528 ArdenleaGrove V258669 131005 AI stage 2.doc Version 1.40 Page 21 A residents’ meeting had been held recently and any issues raised at that time had been resolved to the satisfaction of residents living at the Home. Staff meetings are also held regularly. Quality monitoring visits are undertaken regularly by external Managers and reports of the outcomes of these are sent to CSCI. The management of residents monies in the home safeguards residents interests. A system for formal staff supervision and appraisal had not been commenced, however plans were in place for this. Health and safety checks of equipment used at the Home are undertaken including the fire alarm system, hoisting equipment, gas appliances, emergency lighting and the passenger lift. Some staff had received recent training in respect of fire safety, moving and handling, food hygiene, health and safety, first aid and infection control, however other staff required training in these areas. A fire drill had been undertaken recently. The laundry door was wedged open and this would be a risk in the event of a fire. There were inconsistencies in the staff’s knowledge about the safe fire procedures to follow. A cleaning schedule was in place in the kitchen, however the top of the microwave was found to be dirty and not all foods requiring refrigeration had been stored appropriately and had not been dated when opened. The COSHH store cupboard was found to be open and in addition to this further chemical products had been left unattended in the residents’ corridor. Accident records included detail of any follow up action taken following an accident and these were audited regularly. Ardenlea Grove E54 S4528 ArdenleaGrove V258669 131005 AI stage 2.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 x x 3 2 2 STAFFING Standard No Score 27 2 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 2 3 x x 2 2 x 2 Ardenlea Grove E54 S4528 ArdenleaGrove V258669 131005 AI stage 2.doc Version 1.40 Page 23 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. 2. Standard OP1 OP4 Regulation 4 14(1)(d) Requirement The Organisation is required to further develop the statement of purpose The Acting Manager must confirm in writing to the prospective resident that the Home is able to meet their care needs Residents personal care records must be up to date and identify the actual care given The Acting Manager received this in the form of an immediate requirement Care plans must be written and agreed with the involvement of the resident and/or their representative (timescale of 17/04/05 not met) Continence assessments must include detail of how residents are to be supported in this area (timescale of 17/05/05 not met) Moving and handling risk assessments must include detail of the action to be taken should a resident fall Timescale for action 13/01/06 30/11/05 3. OP7 12(1) 13/10/05 4. OP7 15 30/11/05 5. OP7 12(1) 30/11/05 6. OP7 13(5) 30/11/05 Ardenlea Grove E54 S4528 ArdenleaGrove V258669 131005 AI stage 2.doc Version 1.40 Page 24 (timescale of 30/04/05 not met) 7. 8. OP7 OP7 12(1) 12(2) 13(4) Care plans must identify all nursing care needs of residents living at the Home Risk assessments must be undertaken in respect of residents that chose to go outside of the Home on their own. Appropriate pressure relieving equipment must be provided for residents deemed to be in need of such equipment following assessment The Acting Manager received this in the form of an immediate requirement The nurse call facility must be positioned within the reach of residents at all times whilst being nursed in bed 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 installation of an air conditioning or temperature controlling system is required in all three medication rooms as the temperatures were above 25 degrees Centigrade, to ensure that the medicines are stored in compliance with their product licences to maintain stability The medication refrigerator temperatures must be between 2 and 8 degrees Centigrade at all times to ensure medicines requiring refrigeration are stored in compliance with their product licences to maintain stability The medication policy must be 30/11/05 30/11/05 9. OP8 12(1) 14/10/05 10. OP8 12 13(4) 13(2) 17(1)(a) 15/11/05 11. OP9 17/11/05 12. OP9 13(2) 17/11/05 13. OP9 13(2) 18/10/05 14. OP9 13(2) 17/01/06 Page 25 Ardenlea Grove E54 S4528 ArdenleaGrove V258669 131005 AI stage 2.doc Version 1.40 15. OP10 17(1) Schedule 3 12(4)(a) amended to reflect current practice and staff trained to adhere to the new policy Doors to residents private 13/01/06 accommodation must be fitted with locks suited to the residents capabilities that can be overridden in the event of an emergency. Residents must be provided with keys to their bedroom doors unless their written risk assessment states otherwise (timescale of 17/06/05 not met) Staff must be reminded to respect residents privacy at all times An alternative location must be sought for the telephone provided for residents use in order to afford full privacy for the residents that choose to use it Activities must be provided for residents with dementia care needs and for those residents that are nursed in bed or choose to remain in their bedrooms A written record of activities provided and the residents that participated in each activity must be kept. The adult protection procedure must be reviewed to ensure that arrangements are in place to ensure that the appropriate procedure is followed and authorities are informed with regards to adult protection. (timescale of 17/05/05 not met) All areas of the Home and facilities must be kept clean and fresh Agreed staffing levels must be maintained as a minimum 15/11/05 15/12/05 16. 17. OP10 OP10 12(4)(a) 12(4)(a) 16(2)(b) 18. OP12 16(2)(n) 01/01/06 19. OP12 16(2)(n) 15/12/05 20. OP18 13(6) 01/12/05 21. 22. OP26 OP27 13(3) 16(2)(k) 18(1)(a) 15/11/05 13/10/05 Ardenlea Grove E54 S4528 ArdenleaGrove V258669 131005 AI stage 2.doc Version 1.40 Page 26 23. OP27 18(1)(a) The Acting Manager received this in the form of an immediate requirement Staff must not work an excessive 20/10/05 number of hours each week The Acting Manager received this in the form of an immediate requirement Satisfactory criminal records clearance and two satisfactory written references must be obtained for all staff prior to commencing employment at the Home The Acting Manager received this in the form of an immediate requirement A full audit of staff recruitment personnel files must be undertaken and any information missing from these must be obtained The Acting Manager received this in the form of an immediate requirement Evidence must be available that all Registered Nurses currently practising at the Home hold a live registration entitiling them to practice All staff must be fully aware of their rights and responsibilities in respect of whistle blowing Staff must undertake training in respect of caring with residents with dementia care needs The Organisation must inform CSCI about the future managerial arrangements for the Home A system for formal staff supervision and appraisal must be implemented The COSHH store room must be kept locked at all times and all 24. OP29 13(6) 19(1) 13/10/05 25. OP29 19(1) 13/11/05 26. OP29 19(1) 30/11/05 27. 28. 29. OP30 OP30 OP31 13(6) 18(1) 8 15/12/05 31/01/06 01/12/05 30. 31. OP36 OP38 18(2) 13(4) 01/12/05 13/10/05 Page 27 Ardenlea Grove E54 S4528 ArdenleaGrove V258669 131005 AI stage 2.doc Version 1.40 COSHH items must be stored securely The Acting Manager received this in the form of an immediate requirement Fire doors must not be held open unless by means of suitable door closures that are released in the event of an emergency The Acting Manager received this in the form of an immediate requirement All staff must receive refresher training in respect of all mandatory health and safety issues (timescales of 17/03/05 and 17/06/05 not met) All foods requiring refrigeration must be dated when opened and stored appropriately 32. OP38 23(4) 13/10/05 33. OP38 23(4) 01/01/06 34. OP38 16(2)(j) 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. 2. 3. Refer to Standard OP15 OP29 Good Practice Recommendations It is recommended that the residents are consulted in respect of the devising of new menus It is recommended that interview notes be maintained Ardenlea Grove E54 S4528 ArdenleaGrove V258669 131005 AI stage 2.doc Version 1.40 Page 28 Commission for Social Care Inspection Birmingham & Solihull Local 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. 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