Inspection on 24/10/07 for Ardenlea Grove

This inspection was carried out on 24th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 14/06/06

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 Key Unannounced Inspection 24th October 2007 09:25 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.V349122.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.V349122.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 www.bupa.com BUPA Care Homes (AKW) Ltd Vacant post 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.V349122.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Currently under review 1. The home may provide accommodation, nursing and personal care for one named person under 65 years of age. 14th June 2006 Date of last inspection Brief Description of the Service: Ardenlea Grove is a purpose built care home, which can provide general nursing care for 60 older people who may also have physical disabilities. Ten beds are designated for a continuing care contract with Solihull Primary Care Trust. Built in 1996/7, the premises are located within a development of retirement homes and flats. The home 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. The home is a non-smoking environment but should people wish to smoke a garden area is available and easily accessible. The home has hoists and pressure relieving equipment to meet the assessed needs of the people living there. 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. Each floor has a dining room and spacious lounge. The home has a Loop hearing system fitted into the reception area, which can assist people who have hearing impairments. Previous inspection reports of the home are available from the manager should anyone wish to read them. Current fee rates are not included in the statement of purpose but can be obtained from the home. Additional charges include chiropody, visitor’s meals, hairdressing and toiletries. Ardenlea Grove DS0000004528.V349122.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by us is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. Two inspectors undertook the visit to the home and the acting home manager assisted us throughout. One inspector stayed for the morning and the other for a full day (nine and a half hours). The home did not know that we were visiting on that day. There were 53 residents living at the home on the day of the visit. Information was gathered from speaking to and observing people who lived at the home. Questionnaires were sent out randomly to some people at the home and relatives, but these had not been returned at the time of writing this report. Five people were “case tracked” and this involves discovering individual experiences of living at the home by meeting or observing them, discussing their care with staff, looking at medication and care files and reviewing areas of the home relevant to these people, in order to focus on outcomes. Case tracking helps us to understand the experiences of people who use the service. Staff files, training records and health and safety files were also reviewed. Prior to the inspection the acting manager had completed an Annual Quality Assurance Assessment (AQAA) and returned it to us. This gave us some information about the home, staff and residents, improvements and plans for further improvements, which was taken into consideration. Regulation 37 reports about accidents and incidents in the home were reviewed in the planning of this visit. A random visit had been undertaken in February 2007, to monitor progress since the last key fieldwork visit to the home. Details of this visit will be referred to in the main report. No immediate requirements were made on the day of the fieldwork visit however an urgent action letter was sent after the visit regarding the management of medication and the electrical wiring of the home. We have received an action plan from the home to inform us how they are going to deal with these concerns. What the service does well: The home complete comprehensive pre admission assessments to ensure that both the person and the home know that individual care needs can be met. Ardenlea Grove DS0000004528.V349122.R01.S.doc Version 5.2 Page 6 People are provided with information about the home so that they can make an informed decision about whether they would like to live there. People have access to a range of health and social care professionals and this ensures that any healthcare needs are met. The home offers people a choice of meals, which meet any dietary, cultural needs or personal preferences. There is a friendly and welcoming atmosphere where people can personalise their own rooms to reflect preferences and tastes. A core group of staff is maintained which ensures that people know who will be helping them to meet their needs. People are encouraged to voice their opinions and are actively involved in making decisions about the home and activities. Personal allowances can be held safely by the home if requested. People told us: “Its a good home, its cosy” “We get good care here” “We have good food, I like the breakfast” “The ladies (staff) are nice” “You don’t have to wait too long for them” What has improved since the last inspection? People who come to live at the home are given a contract so that they know what the terms and conditions of residency are. There have been significant improvements to the care plans, which are now written with involvement of the person living at the home and their representatives. Care plans provide specific details so that staff can assist people to meet their individual needs and preferences. Bedroom doors have been fitted with locks so that people can choose to hold a key to their room and maintain their privacy. A newsletter has been implemented, so that people know what is happening in the home, and people are encouraged to contribute to the next edition. Staff have received training relevant to their roles and a training matrix has been devised to assist in the monitoring of training needs. Staff are receiving formal supervision to ensure that they are trained and competent within their roles. Ardenlea Grove DS0000004528.V349122.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ardenlea Grove DS0000004528.V349122.R01.S.doc Version 5.2 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.V349122.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is available for people to make an informed choice about whether they would like to live at the home. Comprehensive pre admission assessments are undertaken so that the person and the home know that their needs can be met prior to admission. EVIDENCE: A copy of the service users guide was taken for review after the visit and was found to contain sufficient information about the service provided by the home, so that people could make an informed decision about whether they may like to live there. It is recommended that this information is also available on audiocassette so that people with visual impairments can access the information. Information was also provided about what the person’s named nurse and key worker can help them to do, so that people know whom they can talk to. Ardenlea Grove DS0000004528.V349122.R01.S.doc Version 5.2 Page 10 People are issued with contracts so that they know the terms and conditions of their stay at the home, and the home offers a four-week trial period so that people can decide if they want to live there permanently. Pre admission assessments were reviewed during this visit and the additional visit in February 2007 and were found to be comprehensive and this ensures that the home can meet the assessed needs of the individual person prior to admission. During our visit people were observed to be shown around the home and staff were answering their questions, which provides information about what it would be like to live there. The home does not provide intermediate care facilities. One person told us “Its a good home, its cosy”. Ardenlea Grove DS0000004528.V349122.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans provide sufficient information for staff to assist people to meet their needs, promoting independence whilst respecting their dignity. The management of medication does not ensure that people receive their medication safely and as prescribed. EVIDENCE: Each person had a care plan written. This is an individualised plan about what the person is able to independently and states what assistance is required from staff in order for the person to maintain their needs. Since the last key visit to the home a new care plan system had been implemented. At the visit in February 2007 the home was in the process of writing the new plans. During this visit five care files were reviewed and these were found to be easy to use and the information was detailed and easily accessible. There were details of people’s past interests, work and family life and likes and dislikes and this will assist staff to help people to meet their individual needs. Ardenlea Grove DS0000004528.V349122.R01.S.doc Version 5.2 Page 12 Care plans were generally specific to individual needs, for example “ “has a square shaped soft pillow to support her head”, “Carries walking stick in left hand”, “likes to use lynx body spray and cuticura moisturiser cream to arms and legs”. The plans also encouraged people to maintain their independence for as long as possible and an example of this was “likes to wash his face himself with a flannel and hot water”. One care plan stated “prefers female carers but can be attended to by male carers for non personal assistance”. This shows that people living at the home are consulted about how they are assisted with their care and who by. Assessments were completed for skin soreness, nutrition and moving and handling. Individual risk assessments were written for specific risks and were detailed. Falls care plans were detailed and addressed all possible causes of falls and gave staff details of equipment to use should someone fall. One person had a urine test, which showed a possible infection, but it was not clear if any action had been taken on these results. Another person had required a prescription for some ointment, this had been followed up by the nurse later the same day, however had still not arrived, and it was not clear from the records if the person had received this treatment. This was brought to the attention of the manager. One person who had been admitted with a terminal illness did not have a care plan written for pain relief. There was evidence of distraction techniques used for people who had unpredictable behaviour. This provides staff with information in order to minimise the potential of this behaviour occurring, therefore keeping the person calm and reducing their distress. A wound care plan was very detailed and gave specific details of wound dressings to be used and how often. There were photographs of the wound so that staff can monitor any changes. There was evidence of visits from external healthcare professionals such as GP, chiropodist, community psychiatric nurse, speech and language therapist, tissue viability nurse and opticians. There was also evidence that people living in the home and their families were involved in the planning and decisions about their care. Residents were appropriately dressed for the time of year and were well presented, wearing clothes and jewellery that reflected their individual choices. Some people had chosen to have their nails painted with nail polish. One person said, “We get good care here”. People are asked if they can attend to their own post or if they would like assistance and are given the opportunity to have a key to their bedroom if they Ardenlea Grove DS0000004528.V349122.R01.S.doc Version 5.2 Page 13 wish and this promotes their privacy. The home has pay phones available but some people had chosen to have their own telephone lines installed so that they could make and receive calls as they chose to. The management of medication was reviewed, photocopies of prescriptions are kept so that staff can check what has been prescribed is delivered to the home. It was of concern that a number of audits completed had incorrect totals, as this does not ensure that people are receiving their medication as prescribed. One person was allergic to paracetamol but had been prescribed this. The chart stated that the person had refused all offers of the medication but staff had failed to act on this and there was a potential risk for the drug to administered. The Medication Administration Records (MAR) indicated that the person had not received the tablets but there were two missing from the box and it could not be determined where they had gone. The manager removed these at the time so that they could not be administered accidentally. Some of the MAR charts had codes recorded, which were not relevant to the reason for the medication not been given. Due to the number of inaccuracies an urgent action letter was sent requiring that an audit of all medications was undertaken and any problems rectified. Room temperatures were recorded and were acceptable. There had been a previous requirement for air conditioning to be installed into the treatment rooms so that medications are stored within their product licence. The manager stated that this is identified in the new budget and in the meantime it is strongly recommended that temperatures continue to be monitored to ensure that they do not go above 25 degrees. If the temperatures go above 25 degrees then action must be taken to ensure the safe storage of medication and dressings. Fridge temperatures are recorded daily and two of the fridges were warmer than they should be and this must be addressed to ensure medications are stored within their product licence. The controlled medication was safely stored and all accounted for. Records were well maintained. Ardenlea Grove DS0000004528.V349122.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are able to exercise their choice over their daily lives and the activities they choose to participate in which promotes their individuality and independence. People receive a varied and wholesome diet, which meets any specific dietary, cultural needs or preferences. EVIDENCE: There is a dedicated activities coordinator for the home and there are a variety of in house activities on offer, which include nail manicures, hand massage, quizzes, karaoke and exercise videos. External entertainment is provided from singers and accordion players, music and movement visit weekly and a reminiscence group also visit. Children from a local school had visited for Harvest festival celebrations and the home were arranging a pre Christmas pamper day, where a beautician would visit and gifts would be available to purchase. Coffee mornings are held and each month there is a theme night. Activities are arranged on various floors and people are encouraged to go to other floors so that they meet other people in the home. Holy Communion is given on the last Wednesday of the month for anyone wishing to receive this and a Catholic priest visits every six weeks. There was Ardenlea Grove DS0000004528.V349122.R01.S.doc Version 5.2 Page 15 no one of any other religion living at the home on this visit but the staff could assist people from other faiths to meet their needs. A hairdresser visits twice weekly so that people can engage in this activity if they choose to. Newspapers are delivered to individual residents as they choose and this means that they can continue to read articles, which interest them. People are encouraged to go out into the community and the activity coordinator will assist people with their shopping. One person attends a club and therefore he is able to persue his interests. There had been two trips out over the summer to a garden centre and the botanical gardens, people had suggested places of interests for ideas for future days out. The home has implemented a newsletter, which tells people about forthcoming events and current items of interest. People living at the home have been asked to contribute to future editions and this shows that people are encouraged to participate in the running of the home. 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 relative’s use. The menus had been changed following consultation with the people who lived at the home. There are two choices of hot meal each lunchtime and snacks are available throughout the day. The home had joined in “British egg” week and “British sausage week” where alternative menus were available. There was also a Halloween supper menu. Since the last visit to the home a “nite bite” system has been introduced so that snacks are available during the evening or night if people are hungry. Dining tables were attractively laid with napkins, flowers, tablecloths and toast racks. Each table had a menu displayed however one person said, “The print on the menus is too small”. This was brought to the attention of the manager and it is recommended that the menus are printed in a larger format so that people with visual impairments can read them. People told us: “We have good food, I like the breakfast” “The food is good” We observed someone in the dining room wearing a bib to protect their clothing however this had been fastened with a clothes peg and this did not promote their dignity. The manager was informed of this at the time of the visit. Ardenlea Grove DS0000004528.V349122.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure, which is accessible to people if they need to make a complaint. The home has policies and procedures in place for staff to follow and this should safeguard people from harm. EVIDENCE: There is a comprehensive complaints procedure and this is on display within the home. The procedure is also included in the statement of purpose and service user guide, so that people know whom they can talk to. The Annual Quality Assurance Assessment (AQAA) indicated that the home had received six complaints since the last key visit to the home. Documentation of these complaints was reviewed and was found to be comprehensive with details of action taken, outcomes and response letters. All complaints were addressed in a timely manner. CSCI had not received any formal complaints about the home. A suggestions box has been implemented so that people can express their opinions and there was evidence of a number of compliments being received, which suggests satisfaction with the service provided. There had been one adult protection referral since the last visit to the home and the case had been closed. The home has a copy of the Solihull Multi Ardenlea Grove DS0000004528.V349122.R01.S.doc Version 5.2 Page 17 Agency Guidelines and an adult protection policy so that staff have guidelines to follow to protect people from harm. Staff receive adult protection training as part of the induction and this training consists of watching a video and then discussing scenarios. Staff are issued with copies of the abuse policy and the whistle blowing policy so that they know what to do if they suspect abuse in order to protect people from harm. Ardenlea Grove DS0000004528.V349122.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,24,25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are provided with a comfortable environment where they appear relaxed. Aids and adaptations at the home ensure that individual needs can be met. EVIDENCE: The home is a three-storey building and access is available to all areas via a passenger lift. All bedrooms have en suite shower and toilet with the exception of six rooms that have a bath. There is a dining room and lounge on each floor, which are spacious and enable people who require mobility aids to manoeuvre freely around the home. Corridors are wide and have handrails to both sides and this assists people to mobilise independently. In addition to the en suite facilities there are communal bathrooms and toilets for people to use. Ardenlea Grove DS0000004528.V349122.R01.S.doc Version 5.2 Page 19 Bedrooms seen were personalised and people had brought in their own items of furniture, which helps them to have comfortable and familiar surroundings. All bedrooms have a nurse call facility so that people can summon help, as they require. Since the last visit to the home, all rooms have had door locks fitted so that people can lock their room if they choose to and this helps people to maintain their privacy. The home has four hoists and two stand aids to assist people who require help with their mobility. The home has pressure-relieving equipment to help prevent people’s skin from becoming sore. One person had a pressure relieving mattress but it was too large for the bed and this was brought to the attention of the manager as may pose a potential risk that the mattress could slip off the bed. Some bedrooms were noticed to have some damage to the walls and the home has a rolling maintenance programme to ensure that all rooms are decorated. Since the last visit to the home twelve bedrooms have been redecorated to ensure that people have a homely environment live in. There is an attractive garden area with seating facilities for residents. Some work had taken place over the summer as the home had received a grant, bird tables and feeders had been purchased and people who were interested had grown tomatoes in hanging baskets. The clinical waste was securely stored on this visit and the manager informed us that there were plans for work to start on this area to make it larger so that bags awaiting collection were safe. The home was generally clean and odour free with the exception of one bedroom which was brought to the attention of the manager at the time. Ardenlea Grove DS0000004528.V349122.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Gaps in the recruitment process do not fully safeguard people from harm. Staff receive training and this ensures that they have the knowledge and skills to perform well within their roles. EVIDENCE: The home has four care staff and one trained nurse on each floor during the morning, three care staff and one trained nurse during the afternoon/evening and one carer and one trained nurse during the night time. On the day of the visit the home had four care staff vacancies and the manager was waiting for recruitment checks prior to staff starting employment. There was also a vacancy for a weekend receptionist. In addition to the care and nursing staff, the home also employs kitchen, domestic, laundry, maintenance and administrative staff. The manager was currently reviewing the staffing levels and was looking at introducing a “twilight shift” as this was a particularly busy time when people needed assistance to go to bed. One person we spoke to said “the ladies (staff) are nice” and another said “you don’t have to wait too long for them”. Ardenlea Grove DS0000004528.V349122.R01.S.doc Version 5.2 Page 21 54 of the staff have completed a National Vocational Qualification (NVQ) level 2 in care and other staff were enrolled onto courses to achieve this qualification. This should ensure that a knowledgeable and skilled workforce is available to provide care to people individually and collectively. Three staff files were reviewed and were found to contain Protection Of Vulnerable Adults first checks (POVA) and Criminal Records Bureau (CRB) checks, references and application forms. One of the files had not had a gap in work history explored and there was no reference from the college, which was the last place of attendance. This does not fully protect people from harm. Two of the staff, who had recently started employment, did not have an identity photograph and this was brought to the attention of the manager at the time of the visit. Qualified nurses Personal Identification Numbers (PIN) were checked with the Nursing and Midwifery Council (NMC) to ensure that nurses were registered and fit to practice. A training matrix has been implemented and this should assist the manager to monitor and plan training to ensure that staff receive training relevant to their role. There was evidence that staff receive training in fire safety, protection of vulnerable adults (POVA), moving and handling, food hygiene, care planning and first aid. Staff are working on distance learning courses in infection control, health and safety and nutrition. A matrix was also in place for planned training. Staff receive induction in line with skills for care to ensure that they are introduced into their role and are given the information to be competent within their role. Ardenlea Grove DS0000004528.V349122.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are systems in place to monitor the quality of the service on offer and the systems for consultation are good. Some health and safety issues require attention to ensure that people who live in the home are safe. EVIDENCE: The acting manager has been in post since November 2005, is a Registered Nurse and has previous experience as a home manager. At the time of the last visit the manager was in the process of applying to us to become the Registered Manager however this had been put on hold due to changes in the management structure of the home. The manager contacted our registration team during our visit in order to continue with her application process. Since the last visit the manager has completed the Registered Managers Award and Ardenlea Grove DS0000004528.V349122.R01.S.doc Version 5.2 Page 23 some internal training, which shows that she is keen to continue to improve her knowledge in order to lead the team. The home holds monthly residents and relatives meetings and this gives people the opportunity to raise any concerns or to share ideas. The meetings also provide a social occasion and give people the chance to have their say about how the home should be run. Prior to the inspection the acting manager had completed the Annual Quality Assurance Assessment (AQAA) and this gave CSCI good detail about the service provided, how it had improved and how the home wanted to improve further over the next year. The manager had a clear vision for how the home could move forward and this should ensure a proactive rather than a reactive approach. External managers provide support to the manager and complete quality monitoring visits to the home. CSCI are informed of the outcome by Regulation 26 reports. Annual questionnaires are sent out to the people who live in the home and the information is collated into an annual report. There is a robust system in place for the handling of people’s personal money and a financial audit is completed by BUPA each year. At the visit in February 2007 staff were not receiving supervision a minimum of six times per year and this is required in order to monitor their competence and training needs. During this visit the manager had devised a supervision matrix, which identified the dates when this was to be done and when actually completed and this should ensure that staff receive this support. Accident records were reviewed and these were in line with the Data Protection Act. The home informs CSCI of accidents and injuries as per Regulation 37. The manager is in the process of implementing an accident monitoring form so that incidents can be monitored and trends identified so that action to minimise the risk can be taken. Records of servicing, tests and maintenance in respect of health and safety for utilities, appliances and equipment such as fire, emergency lighting, passenger lifts and hoists are well maintained. The exception to this was the five yearly electrical wiring certificate, which was “unsatisfactory”. The manager was able to provide some evidence that she had tried to act upon this, however there was no certificate to say that the wiring was now satisfactory. An urgent action letter was issued so that we know that the equipment is safe to use. Senior managers must ensure that any discrepancies are rectified in order to ensure that people at the home are safe. Water temperatures are checked each month and this will ensure that the potential for scalding is minimised. Ardenlea Grove DS0000004528.V349122.R01.S.doc Version 5.2 Page 24 Staff receive fire drills and there was evidence that these had been undertaken, however staff names were not recorded and this does not ensure that the manager can monitor staff to ensure that they have received the recommended two drills per year to ensure that they have the knowledge to safeguard people in the event of a fire. Ardenlea Grove DS0000004528.V349122.R01.S.doc Version 5.2 Page 25 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 X 11 3 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 3 3 3 3 X X 2 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 2 Ardenlea Grove DS0000004528.V349122.R01.S.doc Version 5.2 Page 26 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 OP9 Regulation 13(2) Requirement The management of medications must be reviewed to ensure that people are receiving it as prescribed, and that all medications are accounted for. Timescale for action 05/11/07 2. OP29 3. OP38 The home received an urgent action letter in respect of this. 19 References must be obtained Sch 2 from the last employer/educational establishment to ensure that people are safe. 13(4)(a)(c The unsatisfactory five yearly ) electrical wiring report must be addressed to ensure that people are safe. Previous timescale of 02/03/07 not met. The home received an urgent action letter in respect of this. 19/12/07 09/11/07 Ardenlea Grove DS0000004528.V349122.R01.S.doc Version 5.2 Page 27 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 OP1 OP9 OP15 OP15 OP24 OP29 OP38 Good Practice Recommendations Information about the home should be available in audiocassette so that people with visual impairments can access this easily. Fridge and room temperatures should continue to be monitored to ensure that medication and dressings are stored within their product licence. Menus should be available in larger print so that people can read them. People should wear appropriately fastened protective clothing to promote their dignity. Staff should ensure that air mattresses are placed on an appropriate base, to safeguard people from risk. Staff identity photographs should be available (on files) so that people know who works at the home. The names of staff attending fire drills should be recorded, so that each person receives the recommended two drills per year. Ardenlea Grove DS0000004528.V349122.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-56 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V349122.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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