Inspection on 14/06/06 for Ardenlea Grove

This inspection was carried out on 14th June 2006.

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

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

Other inspections for this house

Ardenlea Grove 13/10/08

Ardenlea Grove 24/10/07

Ardenlea Grove 14/03/06

Ardenlea Grove 13/10/05

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 2AB Lead Inspector Lisa Evitts Unannounced Inspection 14th June 2006 08:25 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 Grove DS0000004528.V298899.R01.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 Grove DS0000004528.V298899.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ardenlea Grove Address 19-21 Lode Lane Solihull West Midlands B91 2AB 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 705 9222 0121 705 9333 doyle@bupa.com BUPA Care Homes (AKW) Ltd Vacant Care Home 60 Category(ies) of Old age, not falling within any other category registration, with number (60), Physical disability (60) of places Ardenlea Grove DS0000004528.V298899.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. May provide accommodation, nursing and personal care for one named person under 65 years of age. May provide accommodation to one named Service User under the registered age of 65 years The home can accommodate one named service user requiring palliative care. 14th March 2006 Date of last inspection 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 and ten beds are designated for a continuing care contract. Built in 1996/7, the premises are located within a development of retirement homes and flats. Ardenlea Grove stands in its own grounds and is situated opposite Solihull Hospital on the main thoroughfare from Solihull to the Coventry Road. It is in close proximity to local shops, local transport services and other community amenities. 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 on the ground floor and has a passenger lift. All bedrooms offer single accommodation and have an en suite facility including an assisted shower or bath. A smoking facility for residents is not provided within the internal environment of the home and a garden area is available and easily accessible. The home has hoists and pressure relieving equipment available to meet the assessed needs of the residents at the home. There are assisted toilets and bathrooms available and corridors are wide and spacious and enable residents to move around the home freely with any aids they require. The home has a Loop hearing system fitted into the reception area, which can assist residents and their visitors who have hearing impairments. Previous inspection reports of the home are available to read in the reception area. The current scale of charges for the home is £840 per week and £910 per week Ardenlea Grove DS0000004528.V298899.R01.S.doc Version 5.2 Page 5 for residents requiring respite care. Ardenlea Grove DS0000004528.V298899.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced fieldwork was undertaken by two inspectors over eleven and a half hours and was assisted throughout by the Manager. There were 48 residents living at the home on the day of the inspection, some residents were receiving hospital care. Information was gathered from speaking with the residents, relatives and staff, from observing care staff perform their duties and from examining care and health and safety records. Medication procedures were reviewed. Staff personnel files were sampled and a partial tour of the building was undertaken. Prior to the inspection the manager had completed a pre inspection questionnaire and returned it to CSCI, and this gave some information about the home, staff and residents that was also considered. One immediate requirement was made on the day of the inspection and a satisfactory response to this was received from the manager a week after the inspection took place. What the service does well: The home complete comprehensive pre admission assessments and send letters of confirmation that care needs can be met to the resident or their representative and this ensures that both the resident and the home know that individual care needs can be met. Residents are generally well supported to meet their health, welfare and social needs by staff at the home, and were well presented. Residents can have newspapers delivered and can choose to have aromatherapy massage at additional costs. Visitors are made welcome into the home and can visit at anytime. The home provides a generally clean, comfortable and homely environment in which to live. Dining rooms, toilets, corridors and assisted baths are spacious and allow the residents freedom to move around the home. There are pressure-relieving mattresses, hoists and handrails available in the home, and this assists residents who have decreased mobility to keep safe. Residents meetings are held and this gives residents the opportunity to raise concerns or to make suggestions as to how improvements could be made. Comments received included: “They are attempting to do more activities” “I go out with my family” Ardenlea Grove DS0000004528.V298899.R01.S.doc Version 5.2 Page 7 “Get plenty to eat” “Food could be better” “I like it here” “I’m alright here Thank You” “Staff are cheerful and happy” “You can’t fault the staff, they are wonderful and will do anything for you” “I would give eleven out of ten to staff, they are lovely and are always there” “The manager is always here and her door is always open” What has improved since the last inspection? What they could do better: Residents must be issued with contracts to ensure they are fully aware of the terms and conditions of stay at the home. Care plans require further development to ensure that more details are recorded in order for staff to provide the individualised care required. Care plans also require monthly reviews and changes in care afforded must be documented to ensure that information is relevant and care is provided in a consistent manner. Residents are offered a choice of meals and a summer menu has been devised, however some negative comments were received regarding the food and the manager must address the individual areas of concern to ensure that all residents are receiving meals to their satisfaction. The home also caters for special diets including pureed meals. Staff training is required regarding PoVA and whistle blowing policies to ensure that staff have the appropriate knowledge and skills to deal with any areas of potential adult protection in an appropriate manner therefore maintaining the safety of the residents. The home must undertake a review of all pressure relieving equipment to ensure that it is appropriate for identified needs and is in full working order. Doors to residents’ bedrooms must be fitted with appropriate locks to give residents the option of keeping their bedrooms secure. Ardenlea Grove DS0000004528.V298899.R01.S.doc Version 5.2 Page 8 Staff must ensure that the nurse call bell is positioned within the easy reach of residents so that help can be summoned when required. The kitchen area requires a deep clean and the kitchenette on the ground floor requires refurbishment to ensure that it is clean and suitable for preparation and cooking of food substances. A staff-training matrix should be devised in order to determine training needs of staff and to ensure that all staff receive statutory updates as required and this will ensure a knowledgeable and skilled workforce provides care. Formal staff supervision sessions must be held at least six times per year in order to address competence of staff and to identify any areas of training, to ensure staff have the knowledge to perform competently in their roles. The home must review the out of hour’s management of the home to ensure that staff know when the manager is on duty, or who is contactable in an emergency. Whilst it is evident that mechanisms are in place, staff at the home are not able to demonstrate this knowledge. 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 DS0000004528.V298899.R01.S.doc Version 5.2 Page 9 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 Grove DS0000004528.V298899.R01.S.doc Version 5.2 Page 10 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, 2, 3, 4 The quality outcome of this area is adequate. This judgement has been made using available evidence including a visit to the service. Prospective residents have some of the information they need to make an informed choice about where to live. Not all residents have contracts issued to inform them of terms and conditions of stay at the home. The home completes assessments and gathers pre admission information and this enables the home to ensure that they can meet the needs of the residents. EVIDENCE: A copy of the Statement of Purpose was taken for review and contained the majority of information required by the Regulations. Further amendments are required to ensure the document meets and covers all of the areas as per schedule one of the Regulations which ensures residents have all access to information they may require about the home. Not all residents at the home are issued with contracts or terms and conditions of stay and the manager must see that all residents are supplied with this information to ensure they are informed of the conditions of stay at the home. Ardenlea Grove DS0000004528.V298899.R01.S.doc Version 5.2 Page 11 Pre admission assessments were reviewed and were found to be comprehensive and this ensures that the home can meet the assessed needs of the residents prior to admission. The manager sends out letters to prospective residents following assessment confirming that the home can meet their assessed needs and this is good practice, as informs residents about decisions made following assessment. The home does not provide intermediate care facilities. Ardenlea Grove DS0000004528.V298899.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 The quality outcome of this area is adequate. This judgement has been made using available evidence including a visit to the service. 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 staff have the information they require to meet individual needs. The management of medication has improved but requires enhancing to ensure that residents receive medication prescribed for them. EVIDENCE: Care plans had been written for all residents at the home that outlined the resident’s needs and actions to be taken by staff to meet these needs. A sample of care plans were reviewed and although they contained some good information, details were not always comprehensive, and some instructions were inappropriate suggesting that some staff lacked knowledge in some aspects of care. Care plans were often not updated. An example of this is one care plan written for risk of developing pressure sores stated to “assess using the Waterlow assessment tool” but didn’t state how often, and “to provide appropriate pressure relieving equipment”, but didn’t state what the appropriate equipment was. One resident was meant to wear specialist Ardenlea Grove DS0000004528.V298899.R01.S.doc Version 5.2 Page 13 stockings and while the resident was wearing these it was not on the care plan to inform staff when they needed to be worn. Another care plan gave instructions for eye care, which was not appropriate. This does not ensure that staff have details to follow to provide the care to meet the individual requirements. Good details were recorded for incontinence aids used and moving and handling equipment. There was also a good care plan for a resident who needed to use a lap belt on the wheelchair during outings outside of the home. Daily records were very detailed with information of changes in condition and details about how the resident had spent their day. Nutritional assessments were completed but resident’s weights had not been consistently recorded. One resident’s care plan stated to be weighed monthly but the weight had not been recorded since February this year and this does not ensure that monitoring is taking place. Care plans had not all been evaluated on a monthly basis and care plans were not always discontinued once the problem was resolved, for example a wound care plan which stated the wound had healed was still in place. There was no evidence of residents or representatives being involved in the care planning process, however the manager had sent out a letter to residents and representatives inviting them to take part in this process. This will be further reviewed at the next visit to the home. A single use syringe for PEG feeding was left out and a multiple use syringe had not been dated when opening or left apart to dry when not in use and this is a potential cross infection risk. Care plans stated to flush tubes before and after meals but didn’t state with what or how much, therefore not providing clear guidance to staff. Charts for residents who require position changes were reviewed and all charts had the same times recorded of 10,12,2,4,6 etc and this is impossible to achieve as staff would be unable to turn all the residents who required this at the same time. On another chart reviewed, it indicated that no turns had been documented since 6am. On discussion with staff it was stated that the turns had been undertaken. Staff must complete the chart for the turn and record the time it actually took place to provide an accurate record of care afforded. Mouth care equipment was not available in all rooms for residents who where nursed in bed and this does not ensure that mouth care is maintained, keeping the resident comfortable and free from infection. Ardenlea Grove DS0000004528.V298899.R01.S.doc Version 5.2 Page 14 During the tour some residents were noted not to be able to reach their call bells and staff must ensure that residents are able to reach these to call for assistance if required. There was evidence of visits from external healthcare professionals such as GP, anticoagulant nurses, chiropodist, dietician and opticians. Residents were appropriately dressed for the time of year and were well presented. The management of medication was reviewed on the first and second floor. Photocopies of prescriptions are kept and there were no gaps on the Medication Administration Records, medications are signed in upon receipt into the home. Prescriptions are not checked with the GP on admission into the home and this must be arranged to be certain that the residents are receiving the correct medication. On the first floor variable dosage medications did not state how many tablets had been administered and therefore there was no audit trail to follow. The amounts of medications administered when variable dose medications are prescribed must be recorded. One resident was using a thickener in her drinks, which had not been prescribed and therefore staff were using another resident’s prescription. This is not acceptable as staff should not be administering unprescribed items and the resident who should be using this would run out of stock. On the second floor the management of medication was very good. Three residents medications were checked and had correct balances. Dupe kits were available for disposal of controlled medications and waste medications were stored in a locked cupboard. New stocks of medications delivered to the home must also be locked in cupboards and the home must make provision for this to ensure that it is stored securely at all times. The room and fridge temperatures continue to remain high and this does not ensure that medication is being stored within its product licence. The Operations Manager for the home stated that they were in the process of obtaining quotes for air conditioning to be installed and it is required that CSCI are kept informed of this progress. Oxygen cylinders were stored in the treatment room while waiting to be collected, these were not in carriers and were not chained to the wall. These are requirements for health and safety of staff and residents. Ardenlea Grove DS0000004528.V298899.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 The quality outcome of this area is adequate. This judgement has been made using available evidence including a visit to the service. Residents are able to exercise their choice over their daily lives and the activities they choose to participate in which promotes their individuality and independence. The meals offered were varied and nutritious but did not meet all the needs of the residents. EVIDENCE: An activities coordinator had been appointed and had commenced employment at the home only the week before the inspection. She was very positive and demonstrated a range of ideas about how the activities could be improved to ensure that individual requests are met and that a variety of activities are on offer. The coordinator had been talking with the residents about their interests to find out what activities they would like and the outcome of this will be further assessed at the next inspection of the home. Comments from residents included: ”They have just appointed a new activities coordinator” “They are attempting to do more activities” Ardenlea Grove DS0000004528.V298899.R01.S.doc Version 5.2 Page 16 Currently activities on offer include hand massage and nail care, board games, flower arranging, card making, a reading group, balloons and music and football lottery. The home had held a barbecue the day prior to the inspection. External entertainment is also provided and includes a pianist and accordion player and music to movement. Aromatherapy massage is available for residents who wish to indulge in this at an additional cost and one resident had chosen to do this. The hairdresser visits twice weekly and the Church of England give a service in the home once a month. Individual visits can be arranged for residents who are Roman Catholics. One resident stated that he had his papers delivered to the home, which encouraged his independence and interests. There are plans for the home to commence a ‘tuck shop trolley’, which will sell sweets and nibbles and some small toiletry items. This idea is commendable as will allow residents to purchase individual items and will provide some choice, particularly for residents who are unable to go shopping or have no relatives to do this on their behalf. There are no rigid rules or routines and residents come and go as they wish. One resident goes to a club and one resident stated, “I go out with my family”. The home has an open visiting policy and there is an option for relatives to join the residents for a meal at an additional cost, the home request that these are booked in advance where possible. A tea and coffee machine is available in the reception for relatives use. Smoking is not permitted within the home and residents are informed of this so they can make an informed choice about living at the home. Residents are offered three full meals a day with a choice at all meal times. The menu is a rolling menu over three weeks, and residents are consulted about meals on a daily basis. A summer lunch and supper menu had been devised, which offered lighter meals. Tables were attractively laid for breakfast and lunch and staff were available to assist to residents requests. Tea and coffee was served in small separate pots, which allowed the residents to pour for themselves as required. It was noted that on the first floor breakfast did not finish until eleven am and this must be reviewed as lunch is served at 12.45, which doesn’t allow much time inbetween meals. Special diets are catered for and this included pureed meals for residents with swallowing difficulties. A number of residents required feeding via a PEG tube and the trained staff administered this. Comments received from residents were varied and included: Ardenlea Grove DS0000004528.V298899.R01.S.doc Version 5.2 Page 17 “Lots to choose from” “Meals not too bad, could be better” “Get plenty to eat” “Food could be better” “Lamb chops you cant get the knife through” One resident stated that a resident meeting is held once a month and they mostly bring up food, but the complaint doesn’t get cured. Minutes of the residents meetings were reviewed and these did detail complaints about food, there was some evidence that the complaints were rectified. The manager must continue to monitor this, and take appropriate action to ensure that resident’s needs are being met and that they are provided with food that meets their cultural, medical needs and individual preferences. Ardenlea Grove DS0000004528.V298899.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The quality outcome of this area is adequate. This judgement has been made using available evidence including a visit to the service. The complaints procedure is comprehensive and is accessible to residents and their visitors should they need to make a complaint. The adult protection procedures may fail to afford full protection for residents. EVIDENCE: The home has a comprehensive complaints procedure on display and this is accessible to residents and visitors of the home. The home has not received any formal complaints since the last inspection and CSCI have not been informed of any complaints pertaining to the home. The staff do not record any informal complaints made, as it was stated they are usually resolved at the time. However it is recommended that the manager keeps a ‘grumbles book’ to record any informal complaints in order to monitor any trends or reoccurrences. This will enable the manager to identify any trends in problems experienced by residents or representatives and enable appropriate action to be taken or systems to be put in place to ensure they do not reoccur. The home has an adult protection policy however this requires some amendments as it states, “the manager will decide what action to take and which external agencies to contact”. This is not in line with multi agency guidelines as Social Care and Health are the lead agency and they would decide what action is to be taken. Ardenlea Grove DS0000004528.V298899.R01.S.doc Version 5.2 Page 19 The homes whistle blowing policy did not have contact details of other agencies available to staff and staff spoken to stated they had not received training in the whistle blowing policy. The manager must make provision for this training to ensure that staff have the knowledge to protect residents at the home without fear of any reprisals. The home does have a copy of the local multi agency guidelines but upon discussion with staff, not all of them knew what the guidance entailed. Some staff stated they had had training in protection of vulnerable adults and gave satisfactory responses to questions asked, however this knowledge was not consistent across all staff interviewed, and this does not afford full protection of the residents. The manager stated that the home had purchased a video about abuse in care homes and all staff were to view this. The manager must ensure that all staff receive training in protection of vulnerable adults, the multi agency guidelines and the action to take in the event of any allegation of abuse, to ensure they have the knowledge to protect residents at the home. Ardenlea Grove DS0000004528.V298899.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 The quality outcome of this area is adequate. This judgement has been made using available evidence including a visit to the service. Ardenlea Grove provided a generally clean, safe, comfortable and homely environment in which to live. Aids and adaptations at the home ensure that residents individual needs can be met. EVIDENCE: The home is a three-storey building and access is available to all areas via a passenger lift. There is an attractive garden area with seating facilities for residents. On arrival at the home, there were staff members available in the reception area and this had improved since the last inspection, which meant that the building was secure for residents. The containers for clinical waste were noted to be overflowing with yellow bags and this had been a requirement at the last inspection, as it poses an infection Ardenlea Grove DS0000004528.V298899.R01.S.doc Version 5.2 Page 21 control and health and safety risk. Upon discussion with the manager she stated there were adequate facilities for disposal of the bags, but staff only use the containers, which are near to the front. The manager will need to address this with all staff at the home to ensure safe disposal of clinical waste. There is a dining room and lounge on each floor, which is spacious and allows residents who require mobility aids to manoeuvre freely around the home. Each floor has two hoists to move residents who require assistance. Corridors are wide and have handrails to both sides and this assists residents to mobilise independently. There are communal assisted baths and toilets available in the home, however the ground floor bathroom had commodes, scales, chairs and a broken stand aid stored in there and these require removing as residents cannot access the facilities. Bedrooms seen were personalised and all rooms are en suite and have a nurse call facility. There are no locks on bedroom doors and this does not ensure that residents have the choice about locking their rooms to maintain their privacy. All rooms have lockable facilities however the manager stated that keys were not available for all of these. It is required that an audit of all rooms is completed and action taken to ensure all residents have a lockable facility with a key enabling residents the choice of using one if required. Pressure relieving equipment in the form of mattresses and cushions was in use for residents who require this, however on one mattress the alarm was turned off. This is poor practice, as staff would not be alerted to any faults occurring with the mattresses and places residents at risk from development of skin sores. One resident had mattresses on the floor to protect her from falling but one of these mattresses had holes in it and needed replacing, as it was no longer fit for purpose. It was noted that some of the pressure reducing equipment had ‘bottomed out’ and therefore was not effective in reducing the risks of skin sores. All mattresses must be at least five inches in depth, and the manager must audit the mattresses and replace any which are not fit for purpose. This suggests that nurses are not fully aware of the various types of equipment for use where residents are identified to be at risk of developing skin sores. It is recommended that the home liaise with the community Tissue Viability Nurses regarding an audit and advice on the equipment in use in the home. Two communal rooms have been redecorated and new armchairs are on order to ensure the residents have a clean and comfortable environment in which to live. One identified bedroom was noted to have an odour and the room required decorating. The home is in the process of completing a maintenance programme and a copy of this must be forwarded to CSCI. Ardenlea Grove DS0000004528.V298899.R01.S.doc Version 5.2 Page 22 The home was generally clean with the exception of underneath a raised toilet seat which required cleaning. The laundry room was visited and there were a number of bags of washing on the floor and there were no disposable gloves available for staff to use. This is both an infection control and health and safety risk. It is recommended that the Infection Control Nurses are invited into the home to audit and advise on any areas of concern. Pillows, towels, quilts and linen were found to be in need of replacing and the manager stated that an audit of linen had been completed and some replacements had been ordered. However, there were a number of items that were not suitable and will need replacing. The kitchen was in need of deep cleaning and quotes had been received for this work to be undertaken. New chopping boards, colour coded knives, some new saucepans, bowls, measuring jugs and a blender are also required to ensure adequate hygiene procedures in the kitchen and suitable equipment for the preparation of meals is available and this was brought to the attention of the manager. Temperatures of fridges are recorded in the kitchen but the fridges in the serving areas on each floor are not recorded and this is required to ensure safe storage of food and beverages. No COSHH risk assessments were available and this does not ensure that potential hazards are recognised and measures taken to minimise the risks, or that staff have details to follow in the event of any problems arising. The kitchen area on the ground floor requires refurbishment to ensure adequate hygiene as the door was broken on the fridge, the sink unit was coming away from the wall, the flooring was lifting and it required decorating. During the last inspection it was felt that some areas of the home were poorly lit, which may pose a risk to the elderly residents with failing eyesight. The manager stated that auxiliary lighting had been provided where necessary and that a questionnaire and audit had been completed to determine resident’s views. Minutes from recent residents meetings did not note any concerns with lighting, however the manager must continue to monitor this. Comments from residents included: “Its a little bit nice here” “I like it here” “I’m alright here Thank You” Ardenlea Grove DS0000004528.V298899.R01.S.doc Version 5.2 Page 23 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 The quality outcome of this area is adequate. This judgement has been made using available evidence including a visit to the service. The home maintains adequate staffing levels. There have been improvements to the recruitment process and this ensures that residents are protected. Staff receive a comprehensive induction programme and this ensures that they have the knowledge and skills to perform well within their roles. Further improvements are required to staff training. EVIDENCE: The home has a vacancy for a kitchen assistant and for three daytime care assistants. Interviews were due to take place to fill the vacancies. In addition to the care staff, the home also employs kitchen, domestic, laundry, maintenance and administrative staff. On review of duty rotas it appears that staffing levels are being maintained satisfactorily. On call support is provided for staff out of hours. Comments from residents included: “You can’t fault the staff, they are wonderful and will do anything for you” “Staff are a little bit nice” “Staff are cheerful and happy” A relative said, “I would give eleven out of ten to staff, they are lovely and are always there” Ardenlea Grove DS0000004528.V298899.R01.S.doc Version 5.2 Page 24 Nine staff have completed Level 2 NVQ and a further five staff are currently working towards this qualification, which will bring the home to the minimum of recommended 50 of staff who hold this qualification. Three staff files were reviewed and were found to contain POVA and CRB checks, references and application forms. The exception to checks was that there was no evidence of a PIN number check for a trained member of staff. This is required for all trained staff, to ensure that they are registered to practice, therefore ensuring the safety of residents. Gaps in work history had been explored and interview checklists were in place. Staff induction programmes are in place and was confirmed as taking place by the newly appointed activity coordinator. The first two days of induction are the same for everyone and then the induction is tailored to the individual needs and role. New documentation had arrived from the organisation and while the booklet stated ‘skills for care’ on the outside the inside of the booklet still referred to TOPPS induction. The home manager is to check the documentation is in line with the Skills for Care programme. There was no formal plan for training in place and no completed training matrix and it is required that a matrix is available for monitoring and planning staff training, and to assist with gathering of information in order to ensure that staff receive all training relevant to their roles to ensure a skilled workforce. Some care planning training had taken place, along with fire training and moving and handling. First aid training and distance learning courses for Infection Control, Health and Safety and Dementia had been arranged. It was recommended that the length and content of courses is recorded for proof of what instructions staff have been given during training. The community dietician is also providing training for staff regarding PEG and enteral feeding, this will cover problem solving, practical work and observation and staff will have competencies to achieve. Ardenlea Grove DS0000004528.V298899.R01.S.doc Version 5.2 Page 25 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 The quality outcome of this area is adequate. This judgement has been made using available evidence including a visit to the service. There is a robust system in place for the management of resident’s personal monies. Improvements are required to staff supervision to ensure that training requirements are identified and staff are supported in their roles. EVIDENCE: The manager has been formally in post since November last year and is currently waiting for her application to become the Registered Manager to be processed. She is a Registered Nurse and has previous experience as a home manager and is currently working towards the Registered Managers Award with BUPA. One member of staff commented, “the manager is always here and her door is always open” Ardenlea Grove DS0000004528.V298899.R01.S.doc Version 5.2 Page 26 On arrival at the home, one of the nurses was unable to state if the manager was on duty that day or when she would be arriving. On discussion with the manager it was determined that there is a site cover rota and the lead nurse has access to a staff locator, so should be able to provide information about when managers will be available. The manager will need to address this with staff to reaffirm that this information is available and where it can be located. The company completes a Resident Satisfaction Survey, the questionnaires for this years survey have been completed and the home is awaiting its report. Whilst this provides some feedback about the service provided by the home, the home must further develop its quality assurance system to include the views of all stakeholders and relatives and draw up an annual development plan outlining outcomes for residents. External managers provide support to the manager and complete quality monitoring visits to the home. CSCI are informed of the outcome by Regulation 26 report. Residents meetings are held and the minutes from these were reviewed. There is evidence that the views of the residents are listened to and acted upon sometimes by the management, however the manager must ensure that resident’s views are always acted upon. Resident’s personal monies were reviewed and the balances were checked and correct. Receipts were available for deposits made. Valuables were being securely stored for one resident at the home but no record had been made of these. A record and receipt of any items held by the home must be in place. Monies available in the residents fund were checked and were correct. The manager had decided on the water feature for the garden, however the use of the residents fund money should be discussed and decided with the residents of the home. Supervision of staff has recently commenced, and the use of group and individual supervision sessions were discussed with the manager. The progress of this will be reviewed during the next inspection at the home, as supervision of staff is important to ensure that staff have the necessary knowledge and skills to perform competently within their roles. Accident records were reviewed. Staff complete the forms, which are then passed to the manager with a report for the shift. This ensures that the manager is aware of any incidents that have happened in the home. The manager completes a quarterly accident audit for the organisation but it is recommended that a monthly audit is undertaken to identify any trends or patterns occurring and to identify any health and safety concerns which may potentially affect the residents. Ardenlea Grove DS0000004528.V298899.R01.S.doc Version 5.2 Page 27 Maintenance records were generally comprehensive with the exception of the five yearly electrical wiring certificate, which was not available. The manager is required to forward a copy of this to the Commission for Social Care Inspection to ensure that the installation is still safe. Wheelchairs are visually checked, however the Operations Manager stated that this was currently under review with the organisation. Until further guidance has been agreed it is required that the home have some written guidelines in place for the maintenance and safety of wheelchairs. The companies review air mattresses as requested, however an annual service must be undertaken for all equipment and the manager must make provision for this. This is to ensure that equipment used is safe and in good working order. Fire records were reviewed and safety checks had been maintained but it was documented that two fire doors had been closing slowly since March and there was no evidence that any action had been taken in response to this problem. An immediate requirement was made that fire doors must close to the rebate in a timely manner. The manager has informed CSCI that new closures have been ordered and are due to be fitted. This will be further inspected at the next inspection of the home. The home is currently in the process of fire training for staff and fire drills are to be undertaken. A fire drill undertaken in January did not indicate the number of staff involved and the home must record names of staff attending, this will also assist in planning of training and further fire drills, to ensure that all staff attend at least two drills per year. Ardenlea Grove DS0000004528.V298899.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 3 3 3 2 3 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 2 1 X 1 Ardenlea Grove DS0000004528.V298899.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 Requirement Timescale for action 29/09/06 2. OP2 5(1)(c) 3. OP7 12(1) 4. OP7 15 The Organisation is required to further develop the statement of purpose. (Previous timescale of 30/05/06 not met.) The manager must ensure that 31/08/06 all residents are issued with terms and conditions of stay at the home. 20/09/06 The registered person must ensure all care plans are individualised following an assessment with residents. They must be comprehensive and outline in detail the action required by staff to meet residents needs and updated when there is any changes in residents conditions. (Timescale of 13/10/05 & 30/04/06 not met.) Care plans must be written and 29/09/06 agreed with the involvement of the resident and/or their representative (Not assessed on this occasion) Ardenlea Grove DS0000004528.V298899.R01.S.doc Version 5.2 Page 30 5. OP8 12(1) 6. 7. OP8 OP8 12(1)(a) 12 13(4) 8. OP9 13(2) 9. OP9 13(2) 10. OP9 13(2) The manager must ensure: Single use syringes are not reused. Oral care must be provided where appropriate. All residents are weighed on a regular basis. (Previous timescale of 15/04/06 not met.) Staff must complete turn charts at the time the turn has been completed. The nurse call facility must be positioned within the reach of residents at all times. (Previous timescale of 15/11/05 & 05/04/06 not met.) Systems must be in place to ensure all medication details are checked when residents are admitted to the home. (Previous timescale of 05/04/06 not met.) 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. (Previous timescale of 17/11/05 & 30/05/06 not met.) 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. (Previous timescale of 18/10/05 & 30/05/06 not met.) 18/08/06 31/07/06 11/08/06 31/08/06 22/09/06 22/09/06 Ardenlea Grove DS0000004528.V298899.R01.S.doc Version 5.2 Page 31 11. OP9 13(2) The manager must ensure that: Variable dose medication has the amount administered recorded. Medications used are prescribed for the individual resident. Medication stocks must be kept in locked cupboards. Oxygen cylinders are chained to the wall and have suitable wheeled carriers. A review of mealtimes must be undertaken . 14/08/06 12. OP15 16(2)(i) 01/09/06 13. OP18 14. OP18 15. 16. OP19 OP19 17. OP19 The quality of meals must be reviewed and must meet needs of all residents. 13(6) The adult protection policy requires some amendments to ensure it is line with the multi agency guidelines. 13(6) All staff must be trained in 18(1) respect of the prevention of abuse, the action to take in the event of an allegation of abuse and the whistle blowing policy. (Previous timescale of 30/06/06) 16(2)(g) The kitchenette on the ground 23(2)(b)(c floor requires refurbishment. ) 16(2)(g) The home must provide new chopping boards, colour coded knives, some new saucepans, bowls, measuring jugs and a blender. 23(2)(d) The manager must undertake an audit of all bedrooms and draw up a plan for redecoration with timescales of when work is to be completed and forward it to the Commission. (Previous timescale of 30/05/06 not met.) 15/09/06 20/09/06 06/10/06 31/08/06 31/08/06 Ardenlea Grove DS0000004528.V298899.R01.S.doc Version 5.2 Page 32 18. OP24 12(4)(a) 19. 20. OP24 OP24 12(4)(a) 23(2)(c) Doors to residents private 31/10/06 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.) An audit must be completed to 08/09/06 ensure that a lockable facility is available in all rooms. A mattress on the floor in one 25/08/06 identified room must be replaced. The manager must complete an audit on all pressure relieving mattresses in the home and replace any that are no longer fit for purpose. Staff must undertake training in the use of pressure reducing equipment. The kitchen requires deep cleaning. Bags of washing must be on trolleys. Disposable gloves must be available for laundry staff to use. The manager must ensure that clinical waste awaiting collection is securely and safely stored. There must be at least 50 of care staff trained to NVQ level 2 or above. (Partly met training ongoing) 21. 22. OP24 OP26 23(2)(d) 16(2)(j) 09/08/06 01/09/06 23. 24. OP26 OP28 16(2)(k) 18(1) 28/06/06 30/10/06 Ardenlea Grove DS0000004528.V298899.R01.S.doc Version 5.2 Page 33 25. OP29 26. 27. OP30 OP30 28. 29. OP31 OP33 30. 31. OP35 OP36 32. OP38 33. OP38 Evidence must be available that all Registered Nurses currently practising at the Home hold a live registration entitling them to practice. (Previous timescale of 30/11/05 & 30/04/06 not met) 18(1)(a)(c A staff-training matrix must be )(i) devised. 18(1) Staff must undertake training in respect of caring with residents with dementia care needs. (Previous timescale of 30/09/06 not met.) (Distance learning courses have been arranged) 8 The manager must seek registration with the Commission. 24 A quality assurance system must be implemented which includes feedback from all stakeholders and a development plan drawn up indicating outcomes for residents. (Previous timescale of 30/07/06) 16(2)(l) A record and receipt of all valuables kept by the home must be maintained. 18(2) A system for formal staff supervision and appraisal must be implemented. (Previous timescale of 11/12/05 not met) 16 (2)(j) All staff must be trained in respect of basic food hygiene and records must be available in the home to demonstrate this. (Previous timescale of 30/06/06) 23(4) All staff must undertake fire drills at least twice a year and records must be available to demonstrate this. (Previous timescale of 30/04/06 not met.) 19(1) 04/09/06 29/09/06 30/09/06 02/10/06 30/10/06 26/07/06 27/10/06 28/09/06 28/09/06 Ardenlea Grove DS0000004528.V298899.R01.S.doc Version 5.2 Page 34 34. OP38 35. OP38 36. 37. OP38 OP38 Staff must be trained in respect of first aid and records must be available in the home to demonstrate this. (Previous timescale of 30/05/06 not met. Training has been arranged) 13(3) All staff must be trained in respect of infection control and records must be available in the home. (Previous timescale of 30/07/06. Training has been arranged) 13(4)(a)(c The manager must forward a ) copy of the five yearly electrical wiring certificate. 13(4)(a)(c Guidelines must be in place for ) maintenance and safety of wheelchairs. Pressure relieving mattresses must have an annual service check. Fire doors must close in to the rebate in a timely manner. (The 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 (Previous timescale of 17/3/05 not met. Training has been arranged) 13(4) 28/09/06 28/09/06 31/08/06 22/09/06 38. OP38 23(4)(a) 20/06/06 39. OP38 23(4) 28/09/06 Ardenlea Grove DS0000004528.V298899.R01.S.doc Version 5.2 Page 35 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. 4. 5. 6. 7. Refer to Standard OP16 OP24 OP26 OP30 OP30 OP31 OP38 Good Practice Recommendations It is recommended that a ‘grumbles log’ is implemented. It is recommended that the Tissue Viability Nurses are invited into the home to audit equipment available. It is recommended that Infection Control Nurses are invited into the home to complete an audit. It is recommended that the length and content of training sessions is recorded. It is recommended that the manager checks the induction programme is in line with ‘skills for care’ It is recommended that out of hours management arrangements are reviewed. It is recommended that a monthly accident audit is completed. Ardenlea Grove DS0000004528.V298899.R01.S.doc Version 5.2 Page 36 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 Grove DS0000004528.V298899.R01.S.doc Version 5.2 Page 37 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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