Inspection on 14/03/06 for Ardenlea Grove

This inspection was carried out on 14th March 2006.

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

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

Other inspections for this house

Ardenlea Grove 13/10/08

Ardenlea Grove 24/10/07

Ardenlea Grove 14/06/06

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 Ann Farrell Unannounced Inspection 14th March 2006 09:00 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.V286059.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ardenlea Grove DS0000004528.V286059.R01.S.doc Version 5.1 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 BUPA Care Homes (AKW) Ltd 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.V286059.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May provide accommodation, nursing and personal care for one named person (NA) under 65 years of age. May provide accommodation to one named Service User (MH) under the registered age of 65 years 13th October 2005 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 to the ground floor and 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. Ardenlea Grove DS0000004528.V286059.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted on an unannounced basis over a full day commencing at 7.45am on 14th March 2005. This is the second inspection for the 2005/2006 year and the report should be read in conjunction with the report from the previous inspection. The manager was not available on the day of inspection and there was no senior nurse to assist with the process. Therefore a number of records about the management of the home were not accessible and there was a lack of knowledge in respect of various aspects about the management and running of the home. During the inspection process the inspector toured the home, sampled residents files and other documentation. Approximately ten residents and four members of staff were spoken to. Resident’s views were generally positive stating they found the staff helpful, but some felt that some staff required more training. Ardenlea Grove DS0000004528.V286059.R01.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Some re-decoration of resident’s rooms needs to be undertaken with improvements in the lighting and locks to bedroom doors to ensure resident’s needs are being met. 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 home must ensure all staff have a beeper to respond to call bells when on duty and demonstrate robust systems are in place for responding to emergency calls in life threatening situations. The general communication and management systems need to be reviewed and action taken to address, shortfalls to include such areas as staff supervision, staff meetings etc. Ardenlea Grove DS0000004528.V286059.R01.S.doc Version 5.1 Page 7 The process of assessment and care planning needs to be improved to ensure all residents’ needs are identified and an accurate plan drawn up to outline in detail how resident’s needs are to be met. Systems need to be in place to ensure they are implemented utilising interventions outlined in the plan of care e.g. for falls. A review of the meals and activities should be undertaken in consultation with residents and changes implemented to meet their needs. The manager must ensure there are systems in place to provide adequate security to the home at all times. The recruitment procedures must be enhanced to ensure they are robust and all checks undertaken prior to employment to adequately safeguard residents. An audit of all existing staff files must be undertaken and checks/documents put in place to meet the regulations. All staff must undertake mandatory staff training to ensure they have the basic skills to meet resident’s needs. Training is also required in areas such as dementia care and abuse prevention. 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.V286059.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ardenlea Grove DS0000004528.V286059.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12-month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 EVIDENCE: The home does not provide intermediate care. Other areas were inspected at the time of the previous inspection. Ardenlea Grove DS0000004528.V286059.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 Residents’ health and personal care needs were generally well met, however some poor care practice and shortfalls in the recording system cannot guarantee resident’s needs are fully met. Further improvements of the medication system are required to ensure residents receive the medication prescribed to them. EVIDENCE: Staff had drawn up care plans for all residents, which outline resident’s needs and the action required by staff to meet their needs. A sample were inspected and it was noted that they were not comprehensive, details regarding the action required to meet residents needs were vague and there were some inaccurate details e.g. one stated that some equipment was in place and in fact it was not present. Also care plans had not been updated when there had been changes in resident’s condition. On discussion with one resident who had recently been admitted to the home she stated that she was able to walk better without shoes due to her poor eye sight. However, the care plan had not noted this aspect and stated she must wear appropriate foot ware. On discussion with staff they were not aware of this fact or why foot ware was necessary. The care plan had not been Ardenlea Grove DS0000004528.V286059.R01.S.doc Version 5.1 Page 11 personalised to the individual residents needs suggesting a routine approach to care In order to provide a consistent approach to care and meet residents needs care plans must be individualised and must outline in detail the action required by staff. All residents are registered with a local G.P. practice and doctors undertake regular visits to the home each week and in between if required. On inspection it was noted some residents did not have access to a call bell: lounges were not supervised and the bed rail on one bed was faulty, which could pose a risk. Single use syringes that had been used for PEG feeds were left in residents suggesting they were used more than once and may pose a risk in respect of infection plus there was no evidence of oral care in the residents rooms. Food charts had not been completed and therefore it could not be determined if residents at risk were receiving an adequate diet. On inspection of records there was evidence that the chiropodist had visited, but there was no evidence that the dentist or optician had undertaken visits and residents had not been weighed regularly. Continence assessments had been undertaken, but on discussion with a nurse they were unable to explain the process or the management of continence suggesting that some training is required in this area On discussion with residents they stated staff were very good and do what ever they can for you, but some are not well trained. Although there is a call bell in each room it was noted that all staff did not have a pager to alert them of calls and some of them are faulty. The manger will need to ensure that staff on duty have a fully operational beeper and robust systems are in place summoning assistance in an emergency where there is a life-threatening situation. The home receives medication regularly and the medication rooms were clean and tidy. On inspection it was found that the fridge temperature and room temperature were above the recommended levels. The home will need to take action to ensure these are within normal limits to ensure medication is stored within the product licence. The medication for waste was not stored in a locked cupboard and there was no disposal kit for controlled drugs on one floor. Some of the audits undertaken were not accurate, in some cases the amount of medication entering the home had not been recorded and an audit could not be undertaken. Handwritten medication details had not been countersigned by two staff and there were some discrepancies in the medication details on the MAR chart when compared with the hospital discharge letter. There must be a robust system in place for checking medication details of all residents entering the home. Also body wash had been prescribed for one resident for five days, but the record stated it had been administered for seven days. Ardenlea Grove DS0000004528.V286059.R01.S.doc Version 5.1 Page 12 On discussion with staff it was stated that there was only on suction apparatus for the home. It is recommended that there should be one on each floor in case of emergency. Ardenlea Grove DS0000004528.V286059.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 The activities currently on offer do not meet resident’s needs and this area needs to be reviewed. The meals and menus need reviewing to ensure a suitably varied diet is available to residents. EVIDENCE: Residents are free to come and go as they wish and there are no rigid rules with the exception of smoking, which is not permitted in the home. There is a relaxed and welcoming atmosphere when entering the home and visiting is flexible. At the last inspection there was an activities organiser in post, but they were no available at the time of inspection. However, on discussion with some residents they stated there was a lack of activities in the home and they would appreciate more. Some residents did go out regularly to places they visited prior to moving into the home. Residents are offered three full meals a day with a choice at all meals. They are consulted about the menu on a daily basis. On discussion with residents there was a mixed response with some stating they were satisfactory to good, but there was a lack of variety. At the time of inspection the chef was not on duty as he had been working several days due to staff shortages in the Ardenlea Grove DS0000004528.V286059.R01.S.doc Version 5.1 Page 14 kitchen. An agency member of staff was on duty, who had not worked in the home before. The manger will need to review the meals and menus with residents to ensure it meets their needs. Tables were laid appropriately for lunch, staff were available and responded to residents requests appropriately providing assistance where required. Ardenlea Grove DS0000004528.V286059.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The arrangements in respect of adult protection procedures may fail to afford full protection for residents. EVIDENCE: The manger was not available at the time and there was no senior nurse to provide assistance. The housekeeping supervisor who was providing assistance was unable to provide details of complaints or the appropriate records. On discussion with some staff they were not aware of the adult protection or whistle blowing procedures. This is rather concerning and needs to be addressed through training. Ardenlea Grove DS0000004528.V286059.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25, 26 Ardenlea Grove provides a generally clean, safe, comfortable and homely environment for residents to live in. Areas in respect of lighting and locks to doors need to be addressed to ensure resident’s needs are met. EVIDENCE: The home is a modern three-storey building, which is cleaned to a good standard and well maintained. There is access to all areas via a passenger lift. On arrival the main door was open and the reception area was not staffed, which was concerning in respect of the security of the home. It was also noted that the container for clinical waste, which is at the front of the building was overflowing with yellow bags containing clinical waste. This could pose a risk in respect of infection control. An immediate requirement was left with the home to address this area urgently. There is a dining room and lounge on each floor, which are pleasantly decorated and furnished to a good standard. In addition, there is seating in the reception area. Ardenlea Grove DS0000004528.V286059.R01.S.doc Version 5.1 Page 17 All bedrooms are provided with en-suite facilities and a call bell, but there are no locks on bedroom doors. Samples of bedrooms were inspected and were found to be personalised by residents. However, the décor was rather tired and showing signs of wear and will require re-decoration. All areas inspected were cleaned to a good standard. In addition to the en-suite facilities there is a range of assisted baths and showers on each floor and toilets are strategically placed through the home. Rooms are individually and naturally ventilated and windows are provided with restrainers for safety and security reasons. Radiators are of the low surface temperature type and water from hot water outlets is regulated to reduce the risks of accidents from scalds. On touring the home the inspector felt that some areas were poorly lit and on inspection of records from residents meetings it was noted that some residents had also complained about this aspect. However there was no evidence that any action had been taken to address this issue. The manger must ensure that this area is followed up and lighting is in place that meets resident’s needs to reduce the risk of accidents, which may be associated with failing sight with the increased aging process. It was also noted that the radiator in one room was not working. Action must be taken to ensure the system is working effectively throughout the home. The main kitchen is situated in the basement. A full inspection was not undertaken as an agency chef was on duty, but it was noted that the microwave and storeroom required more through cleaning and sauces had not been stored appropriately after opening. On inspection of the laundry area it was rather cold and one of the tumble dryers was not working. On discussion with residents it was stated that on a number of occasions items of clothing had gone missing. The laundry systems will need to reviewed and action taken to address this issue. Ardenlea Grove DS0000004528.V286059.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 Records indicate that adequate staffing levels are being maintained. Poor staff recruitment practice fails to afford full protection for residents living at the Home. EVIDENCE: On inspection of duty rotas and discussion with care staff it appeared that staffing levels were being maintained to a satisfactory standard now. However, there are still instances of staff working long hours each week. Kitchen, domestic, laundry, administrative and maintenance staff provide support to the care staff on duty and there was still a vacacny for a cook. A sample of staff files were insepcted as the recrutiment process was found to be poor at the last insepction. On inspection it was noted that some nurses PIN numbers had not been checked to determine if they were currently registered to practice. In some cases there was no proof of identity or permission to work in this country and no CRB or POVA check. The manager must ensure a full audit of staff files is undertaken and all relevant checks undertaken to ensure a robust recruitment process. An immediate requirment was made in respect of this area. The manager was not on duty and the information regarding NVQ training for staff was not availble. The manager must ensure at least 50 of care staff are trained to a minimum level of NVQ 2 in care. Ardenlea Grove DS0000004528.V286059.R01.S.doc Version 5.1 Page 19 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, 38 A review of the management arrangements should be undertaken to provide a more robust system. The health, safety and welfare of residents could be further protected by the provision of a range of mandatory training for staff. EVIDENCE: An acting manager has been in place since the last inspection, but no application has been received by the Commission for registration. The responsible person must ensure an application is forwarded to the Commission for the registration of a manager. At the time of inspection the manger was not available and there was no senior nurse to assist with the inspection process. A number of records could not be accessed and the staff on duty were not aware of aspects in relation to the management and running of the home. It is recommended that the management arrangements be reviewed to ensure more robust systems are in Ardenlea Grove DS0000004528.V286059.R01.S.doc Version 5.1 Page 20 place. There was no evidence of a quality assurance system or monthly visits on behalf on the responsible person. The record of staff training could not be accessed to determine if all staff had undertaken mandatory training. On discussion with some staff there was a lack of clarity about fire procedures and a recent notification in respect of regulation 37 identified that some staff had not dealt with an accident appropriately. This indicates that staff require training in respect of fire prevention, fire drills and first aid. The manger will need to ensure all staff undertake the required mandatory training to include basic food hygiene, manual handling and infection control. Ardenlea Grove DS0000004528.V286059.R01.S.doc Version 5.1 Page 21 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 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 3 3 X 3 3 2 2 STAFFING Standard No Score 27 3 28 2 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X X X X 2 Ardenlea Grove DS0000004528.V286059.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? Yes Ardenlea Grove DS0000004528.V286059.R01.S.doc Version 5.1 Page 23 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 The Organisation is required to further develop the statement of purpose. Not inspected and carried forward from 30/1/06 The Acting Manager must confirm in writing to the prospective resident that the Home is able to meet their care needs. Not inspected and carried forward from 30/11/05. 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 not met. Care plans must be written and agreed with the involvement of the resident and/or their representative Timescale of 17/4/05 not met. Continence assessments must include detail of how residents are to be supported in this area Timescale of 17/5/05 not met. Moving and handling risk assessments must include detail DS0000004528.V286059.R01.S.doc Timescale for action 30/05/06 2. OP4 14(1)(d) 30/04/06 3. OP7 12(1) 30/04/06 4. OP7 15 30/04/06 5. OP7 12(1) 30/04/06 6. OP7 13(5) 30/04/06 Ardenlea Grove Version 5.1 Page 24 7. OP7 12(2) 13(4) 8. OP8 12(1) 9 OP8 12(1) 10 OP8 12(1) 11 OP8 13(1) 12. OP8 12 13(4) 13(2) 13. OP9 of the action to be taken should a resident fall Timescale of 30/4/05 not met. Risk assessments must be undertaken in respect of residents that choose to go outside of the Home on their own. This area was not assessed and has been carried forward from 30/11/05. Appropriate pressure relieving equipment must be provided for residents deemed to be in need of such equipment following assessment and all staff must be aware of residents needs in this area. Timescale of 14/10/05 not met. The manager must ensure: • Single use syringes are not re-used. • Oral care must be provided where appropriate. • Food charts must clearly state is residents have been offered food. • All residents are weighed on a regular basis. The registered person must ensure all staff have a pager to alert them of residents calls and be able to demonstrate a robust system is in place to respond to emergency calls in life threatening situations. An immediate requirement was made. The manager must ensure all residents have the opportunity to see a dentist and optician on a regular basis and this is recorded. The nurse call facility must be positioned within the reach of residents at all times. Timescale of 15/11/05 not met. There must be: DS0000004528.V286059.R01.S.doc 30/04/06 30/04/06 15/04/06 30/04/06 30/05/06 05/04/06 05/04/06 Page 25 Ardenlea Grove Version 5.1 17(1)(a) 14. OP9 13(2) 15. OP9 13(2) 16. OP9 13(2) 17(1) Sch3 A robust procedure in the home for receiving, administration and recording of all medication. • There must be a disposal kit for controlled medication on all floors. • All waste medication waiting for disposal must be stored in a locked cupboard. • Two members of staff must check and countersign all handwritten medication details. • Systems must be in place to ensure all medication details are checked when residents are admitted to the home. The installation of an air 30/05/06 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. Timescale of 17/11/05 not met. The medication refrigerator 30/05/06 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. Timescale of 18/10/05 not met. 30/06/06 The medication policy must be amended to reflect current practice and staff trained to adhere to the new policy. This area was not assessed and has been carried forward from 17/1/06. • Ardenlea Grove DS0000004528.V286059.R01.S.doc Version 5.1 Page 26 17. OP10OP24 12(4)(a) 18. OP10 12(4)(a) 16(2)(b) 19. OP12 16(2)(n) 20 OP15 16(2)(i) 21. OP18 13(6) 22 OP18 13(6) 18(1) 23 OP19 13(4) Doors to residents private 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 17/6/05 not met. 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. Timescale of 15/12/05 not met. A review of activities must be undertaken and a meaning plan drawn up and implemented based on residents past interests and hobbies, which includes residents with dementia and who are nursed in their rooms. Timescale of 1/1/06 not met. A review of the meals and menus must be undertaken to ensure there is a varied diet that meets resident’s needs. 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. Not assessed and has been carried forward from 01/12/05. All staff must be trained in respect of the prevention of abuse, the action to take in the event of an allegation of abuse and the whistle blowing policy. The manager must ensure the main door is kept locked when the reception area is not staffed. An immediate requirement was DS0000004528.V286059.R01.S.doc 30/06/06 30/06/06 30/05/06 30/05/06 30/04/06 30/06/06 01/04/06 Ardenlea Grove Version 5.1 Page 27 24 OP19 16(2)(j) 25 OP19 23(2)(d) 26 OP25 23(2)(p) left with the home. The manger must ensure systems are in place for all areas to be cleaned to a satisfactory standard and all food items are stored appropriately 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. The manager must ensure the radiators in resident’s rooms are working effectively and lighting is sufficient to meet their needs. The manager must ensure: • Adequate heating and ventilation in the laundry. • Adequate drying facilities. • Undertake a review of the laundry system and implement any necessary changes to ensure residents personal items are returned. The manager must ensure there are adequate systems in place for the removal of clinical waste. An immediate requirement was left with the home. There must be at least 50 of care staff trained to NVQ level 2 or above. Satisfactory criminal records clearance and two satisfactory written references must be obtained for all staff prior to commencing employment at the Home Timescale of 13/10/05 not met. A full audit of staff recruitment personnel files must be undertaken and any information missing from these must be obtained An immediate requiremen was DS0000004528.V286059.R01.S.doc 30/04/06 30/05/06 30/04/06 27. OP26 23(2)(c) 12(1) 30/04/06 28. OP26 18(1)(a) 01/04/06 29 30. OP28 OP29 18(1) 13(6) 19(1) 30/10/06 30/04/06 31. OP29 19(1) 30/04/06 Ardenlea Grove Version 5.1 Page 28 32. OP29 19(1) 33. OP30 18(1) 34. OP31 8 35 OP33 26 36 OP33 25 37. OP36 18(2) 38 OP38 13(5) 39 OP38 16(2)(j) 40 OP38 23(4) left with the home. Timescale of 13/11/05 not met. Evidence must be available that all Registered Nurses currently practising at the Home hold a live registration entitiling them to practice. Timescale of 30/11/05 not met. Evidence of staff’s eligibility to work in the U.K. must also be available. Staff must undertake training in respect of caring with residents with dementia care needs. Timescale of 30/01/06 not met. The responsible person must ensure an application is forwarded to the Commission for the registration of a manager. The responsible person must ensure a monthly visit is undertaken to determine the standard of care in the home on an unannounced basis and reports are available in the home. A quality assurance system must be implemented which includes feedback from all stakeholders and a development plan drawn up indicating outcomes for residents. A system for formal staff supervision and appraisal must be implemented. This are was not assessed and has been carried forward from 11/12/05. All staff must be trained in respect of moving and handling and records must be available in the home to demonstrate this. All staff must be trained in respect of basic food hygiene and records must be available in the home to demonstrate this. All staff must be trained in respect of fire prevention and DS0000004528.V286059.R01.S.doc 30/04/06 30/09/06 30/05/06 30/04/06 30/07/06 30/06/06 30/05/06 30/06/06 30/04/06 Page 29 Ardenlea Grove Version 5.1 41 OP38 13(4) 42 OP38 13(3) 43. OP38 23(4) undertake fire drills at least twice a year and records must be available to demonstrate this. Staff must be trained in respect 30/05/06 of first aid and records must be available in the home to demonstrate this. All staff must be trained in 30/07/06 respect of infection control and records must be available in the home. All staff must receive refresher 30/06/06 training in respect of all mandatory health and safety issues Timescale of 17/3/05 not met. 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 OP9 OP29 OP31 Good Practice Recommendations It is recommended that one suction machine be available on all floors. It is recommended that interview notes be maintained. It is recommended that the management arrangements in the home be reviewed. Ardenlea Grove DS0000004528.V286059.R01.S.doc Version 5.1 Page 30 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. 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