Inspection on 02/05/06 for Ascot Nursing Home

This inspection was carried out on 2nd May 2006.

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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ascot Nursing Home 19/09/07

Ascot Nursing Home 18/10/05

Ascot Nursing Home 04/05/05

Similar services:

21 High Street

Vale House

Chestnut Walk

The Old Vicarage

Cherwood House Care Centre

Ashley House

Fountain View

Wardington House Nursing Home

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Ascot Nursing Home Burleigh Road Ascot Berkshire SL5 7LD Lead Inspector Yvonne Souden Unannounced Inspection 02:00 2 & 3rd May 2006 nd Ascot Nursing Home DS0000062218.V290318.R01.S.doc Version 5.1 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 Ascot Nursing Home DS0000062218.V290318.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 and Care Homes for Adults 18 – 65*. 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. Ascot Nursing Home DS0000062218.V290318.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ascot Nursing Home Address Burleigh Road Ascot Berkshire SL5 7LD 01344 620656 01344 621606 jillchuascot@aol.com 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) Ascot Nursing Home Limited Mrs Jill Chufungleung Care Home 72 Category(ies) of Dementia (15), Dementia - over 65 years of age registration, with number (29), Mental disorder, excluding learning of places disability or dementia (22), Mental Disorder, excluding learning disability or dementia - over 65 years of age (26) Ascot Nursing Home DS0000062218.V290318.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th October 2005 Brief Description of the Service: Ascot Nursing Home is an Edwardian House with a purpose-built extension set in its own grounds close to Ascot Village and Ascot Racecourse. The home is registered to provide nursing care for up to 72 people who have mental health needs, consisting of people who suffer from dementia or a mental disorder either in older age or under 65 years of age. The nursing home is divided into three units each function independently with unit offices, dining rooms, sitting rooms and distinctive staff teams. Unit one cares for residents of all ages who have been diagnosed as suffering from moderate to severe dementia. Unit two cares for older residents who have enduring mental health needs, and may need physical assistance. The Wrens unit cares for residents with enduring mental health needs who are generally able to maintain their own physical care with support and encouragement. The home has a newly appointed Head of Care. The registered manager Mrs Jill Chufungleung is responsible for the overall management of the home. Ascot Nursing Home DS0000062218.V290318.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Part of the inspection process looked at records and information that included residents’ surveys prior to the inspector visiting the home, and further records and information whilst visiting the home. The inspector visited the home over two days, day one from 2 p.m to 8 p.m and day two from 10 am to 6 p.m. At the visit the Inspector spoke to residents, visitors, staff, management and a visiting GP. What the service does well: What has improved since the last inspection? The home has made some improvements since the last inspection following requirements and recommendations made and as a result of two adult protection investigations. The home has reviewed the structure of the senior staff team and has introduced a ‘Head of Care’; this is viewed as a positive step forward in meeting the needs of the residents. Staff receive supervision regularly and their weekly working hours have been reviewed to ensure they are competent in meeting the needs of the residents. Residents and their relatives are being consulted and involved in the residents care plans, and a review of how care plans are written has begun. The manager and head of care are reviewing the way they monitor care practice and health and safety within the home, and a three-year redecoration/refurbishment plan of the home has begun. Ascot Nursing Home DS0000062218.V290318.R01.S.doc Version 5.1 Page 6 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. Ascot Nursing Home DS0000062218.V290318.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Ascot Nursing Home DS0000062218.V290318.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) 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 Quality in this outcome area is good. This judgment has been made using available evidence including a site visit to the service. Service users are informed of the service provided and their needs are assessed prior to their admission, although further information could be sought to improve the quality of the assessment. EVIDENCE: The home has a statement of purpose and service users guide that is reviewed annually, and has an information handbook available to all as you enter the building. Discussions with service users and relatives identified that the service users needs are assessed by the manager, prior to them coming to live in the home. A relative of a service user said I visited the home prior to my husband being Ascot Nursing Home DS0000062218.V290318.R01.S.doc Version 5.1 Page 9 admitted, the manager assessed his needs and he was offered a permanent placement. Needs assessments viewed on the day of the site visit identified that the manager had collated information received from the service user and their relative/representative, and from health and social care professional assessments. Further information could be obtained on the service users life history as in some areas this was limited and could be vital within the development of person centred care plans. Ascot Nursing Home DS0000062218.V290318.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) 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, 7, 8, 9, 10 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to the service. Service users care plans reflect their health and social care needs, but do not reflect their holistic/ cultural/recreational care needs that could result in unidentified risks. Service users are supported to maintain community contact and make decisions in their lives. Service users records are stored confidentially but some recording practice could jeopardise this. EVIDENCE: The care plans and risk assessments of five service users were viewed and identify that they concentrate on the service users health and psychological needs, but do not give the same consideration to the service users interests gained historically or presently, and do not fully address the service users recreational, social, cultural and religious needs. The newly appointed Head of Ascot Nursing Home DS0000062218.V290318.R01.S.doc Version 5.1 Page 11 Care and Registered Manager expressed their enthusiasm to further develop care plans using a care programme approach that should ensure they are person centred. As quoted by one service user I have a key worker, Im going to review my care plan with my key worker and head of care, we have spoken about it today, and as quoted by a relative, care plans, the nurse showed me, I sign the care plan if I agree. A requirement was made at the previous inspection to review and implement new care plans, but a new time scale has been given due to the change in management structure realistic timescales in developing new care plans and staff developing care plan/risk assessment training. Daily records are maintained, but care staff record daily findings of all service users’ within one small notebook that is transferred to the individual service user’s daily record by the nurse in charge. Discussions with the head of care and manager identified that records maintained by care staff could be entered into the service users individual record in the first instance and then countersigned by the nurse in charge who may have other information to add. This will decrease the duplication of records and will ensure one source of record is maintained individually as opposed to collectively. Service users and their relatives spoke of monthly resident/relative audit meetings and of the home’s newsletter that allows them to contribute to decisions made within the home. As quoted by a service user I feel listened to and taken seriously, and as quoted by a relative, we come to resident/service user meetings, there is one on the 8th May. Ascot Nursing Home DS0000062218.V290318.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. 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. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. The judgment has been made using available evidence including a visit to the service. Daily living and activities made available are flexible and varied and service users are supported to exercise choice and control of their lives. Service users enjoy a healthy diet and maintain links with family, friends and the community. Ascot Nursing Home DS0000062218.V290318.R01.S.doc Version 5.1 Page 13 EVIDENCE: Surveys and discussions with service users and their relatives identified that service users feel they are treated with dignity and respect, and are supported in their decision-making. Staff were observed to be attentive to the service users and were seen to offer support and guidance as needed. Choice of menu and attractively presented meals was evident at the two-day site visit. As quoted by a service user meals are pretty good, chicken is my favourite, and as quoted by a relative meals are good, they have a choice, I came and had Easter Sunday lunch it was very nice. The home has an activity co-ordinator and five activity assistants who develop group and individual service user activity programs. The individual service user programs of activity could be further developed from information drawn from the service users life history as discussed within section 2 of this report. A small animal farm visited the home on day one of the unannounced site visit, and there was evidence of recreational activity taking place. As quoted by a service user I keep busy and help to put the newsletters in the envelopes, we go out in the minibus and will probably do this more often as the weather becomes warmer, and as quoted by a relative we get newsletters that informs us what is going on, some of the service users went out on a trip to the coast last Friday. Over the two-day site visit the Inspector observed visitors come and go and observed service users to freely move around the home. Discussions with staff identified their awareness of the needs of the service users and as quoted by staff some service users choose not to participate, we ask the service user what they want to do and will look at their changing needs so that they dont get bored, and some service users like to keep to themselves whilst some enjoy trips within the community, we have a fete scheduled in July everyone gets involved”. Ascot Nursing Home DS0000062218.V290318.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) Service users retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicines. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgment has been made using available evidence including a site visit to this service. Service users are treated with dignity and their privacy is respected as their personal needs and health care needs are met. EVIDENCE: A visiting GP confirmed that the GP holds a surgery within the home twice weekly and reviews the service users health care/medication annually. The home uses a monitored dosage system (MDS) in the administration of service users medication and has quality assurance procedures in place to ensure auditing of medication. The home has a pharmacy inspection every three months on the administration, storage and disposal of medication; date of last pharmacy inspection 22/03/06. The report indicates no problems identified on unit one and two, but informed of gaps in the medication records on Wrens Ascot Nursing Home DS0000062218.V290318.R01.S.doc Version 5.1 Page 15 and of an unsecured medication trolley containing creams. Case tracking of service users records identified that medication records were complete. Incident and accident records show that minor and major incidents/accidents are acted upon and recorded. Service users daily records and medication records identify consultations with health care professionals and treatment received. Records also identify that service users are enabled to attend health care consultations, and that regular reviews are held to ensure their health and social care needs are met. Discussions with staff identified their awareness of the service users needs, and training records show that staff receive training to support the service users health and social care needs for example dementia care, mental health/care programme approach (CPA), first aid and infection control. Further development within the service users care plans as discussed within section 2 of this report is needed to identify the service users personal care needs, associated risks and of how those needs are to be met and risk minimised. Staff were observed to be courteous to the service users and observed to ensure service users personal care needs were met in privacy. Ascot Nursing Home DS0000062218.V290318.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is adequate. This judgment has been made using the available evidence including a visit to the service. Service users feel their views are listened to and acted on, but some service users would disagree. Policies and procedures are in place to protect service users from abuse, neglect and self-harm, service users financial interests are safeguarded. EVIDENCE: On day one of the inspection some staff were receiving abuse awareness training; training programs and staff training certificates identified various dates that abuse awareness training had been delivered. Discussions with staff identified their knowledge of what constitutes abuse and of what action to take should they suspect or witness an abusive situation. The home has policies and procedures on the protection of vulnerable adults that have been accessed twice since last inspection in October 2005. Positive outcomes have been gained from strategy meetings held in the recruitment of a head of care and plans to develop positive communication systems within the home. The home has a complaint logbook that records concerns/complaints made with an action plan to resolve the concern/complaint. The complaint procedure is available within the homes statement of purpose and service users guide, and is within the homes Handbook available on entering the home. As quoted by a relative, If I was unhappy about anything in the home I would feel Ascot Nursing Home DS0000062218.V290318.R01.S.doc Version 5.1 Page 17 confident to talk to them, they are all a nice crowd they listen to you. Service user surveys identified that service users know who to speak to if they were unhappy and know how to make a complaint, but some service users are not sure whether they would be listened to. Records identify that systems are in place to protect service users from financial abuse. Ascot Nursing Home DS0000062218.V290318.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. Service users live in a homely, comfortable, clean and safe environment that requires some further redecoration and furnishing to enhance the homeliness of the home. EVIDENCE: The home has met the requirements made at the last inspection as the manager has reviewed the environment within the wrens units and the general décor and furnishings within the home. The manager submitted a three-year redecoration/refurbishment programme to CSCI. Ascot Nursing Home DS0000062218.V290318.R01.S.doc Version 5.1 Page 19 The provider and manager discussed the refurbishment programme with the Inspector confirming that wear and tear to décor and furnishings is increased within the home due to the needs of the service users. It was identified that this would need to be addressed within the homes business plan to establish whether a three-year refurbishment plan meets the needs of the service users to ensure they continue to live in a comfortable and homely environment. The corridor within the dementia care unit is long and narrow and has been repainted; the walls, doors and flooring are of the same colour and do not provide an inviting environment for those people who have dementia. The manager confirmed recent training on dementia care and positive ideas to improve the environment for those people with dementia. There was evidence within the tour of the building that redecoration/refurbishment within some areas of the home has commenced as identified within the homes décor/refurbishment plan, and that a new staffroom is in the process of being built. The home was observed to be clean with no offensive odours, and systems were observed to be in place to promote the health and safety of the service users, staff and visitors. Windsor and Maidenhead planning and environment visited the home on the 14th March 2006 to carry out a food safety inspection of the premises. Four requirements were made with the compliance date 14th March 2007, and one recommendation was made. The manager confirmed action taken to date to meet those requirements. Ascot Nursing Home DS0000062218.V290318.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Service users are supported by competent, trained and qualified staff, and are protected by the homes recruitment policy and practices. EVIDENCE: Day one of the site visit saw abuse awareness training taken place. Discussions with staff, training programs and certificates seen provide evidence that staff are supported within their training needs to meet the needs of the service users. As quoted by staff we attended communication training, this was also evident from discussions with the training manager and the viewed programme of communication training that had been delivered based on verbal and body language. Staff spoke positively about training attended internally and externally and are supported in achieving a National Vocational Ascot Nursing Home DS0000062218.V290318.R01.S.doc Version 5.1 Page 21 Qualification in care at level 2 and 3. At the time of inspection 41 of care staff had an NVQ with a projected increase to 72.4 as care assistants complete the NVQ course they are currently undertaking. There was evidence to show that new staff have commenced an induction in line with the new common induction standards as developed by skills for care. Skills to Care have recently evaluated the homes training programme and individual training needs of staff, presenting staff with individual skill profiles that can serve as a training and development tool. Staff records identified that service users are protected by the homes recruitment practice; one file did not contain the work history of the staff member, but the information was obtained within the inspection process. Discussions with staff and records of supervision seen identified that supervision has been implemented to support staff in meeting the needs of the service users and contributing to positive communication systems. The staff Rota identifies that staff are sufficient in numbers to meet the needs of the service users and identifies that agency staff have not been used. Staff continue to work 14 hour shifts; following the requirements made at the previous inspection management have improved the rota by ensuring staff do not work any more than two days without having a day off, have increased staff breaks and are in the process of making improvements as to where staff can have their break. Ascot Nursing Home DS0000062218.V290318.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Service users benefits from a well run home and are confident that their views are listened to in the review and development of the home. Service users are protected by the homes health and safety practices. Ascot Nursing Home DS0000062218.V290318.R01.S.doc Version 5.1 Page 23 EVIDENCE: Records seen and discussions with management, service users, relatives and staff provide evidence that meetings are held within the home that ensures the views of all underpin the development of the home. Information discussed within senior staff meetings is cascaded to care staff within unit meetings by the nurse in charge. Minutes from the unit meetings are handwritten in a small notebook and are not always legible; this could contribute to communication breakdown as not all care staff can attend the unit meetings held at weekends only. The manager and head of care are enthusiastic about their plans to improve communication within the home for example introducing new communication books, improving minutes of meetings and choice of dates that meetings are held, and improving care plans and risk assessments as discussed within section 1, 2 and 3 of this report; this is viewed as a positive step to improving overall communication systems within the home that will contribute to the service users health and social care needs being met. Service users and their relatives say that management are approachable and staff say supervision has improved, staff feel supported by management. Quality assurance records dated 28/04/06 identifies that the home has a quality assurance system in place that measures outcomes. Discussions with management and records seen identify that the manager and head of care are in the process of developing new auditing system that measures outcomes against each National Minimum Standard. Fire records identify that fire safety checks are maintained, and discussions with staff and training records seen provide evidence that staff receive mandatory training within health and safety. From a tour of the building it was observed that health and safety is promoted throughout the home. The home was clean and tidy and staff used protective clothing and disposal facilities that promote infection control. Ascot Nursing Home DS0000062218.V290318.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT Standard No Score 37 3 38 X 39 3 40 X 41 X 42 3 43 X 2 3 3 2 2 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ascot Nursing Home Score 3 3 3 X DS0000062218.V290318.R01.S.doc Version 5.1 Page 25 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6YA9 Regulation 15 13 (4) Requirement The manager must provide CSCI with an outline plan of action that will see the development of improved service user care plans/risk assessments. The action plan must link dates for staff to attend care-planning/risk assessment training to ensure successful implementation. The care plans/risk assessments must be user friendly and person centred that considers the service users health and social care needs holistically and presently. (Previous timescale 30/11/05 not met) The manager must provide CSCI with an outline plan of action that will see the development of improved service user care plans/risk assessments. The action plan must link dates for staff to attend care-planning/risk assessment training to ensure successful implementation. The care plans/risk assessments Ascot Nursing Home DS0000062218.V290318.R01.S.doc Version 5.1 Page 26 Timescale for action 13/06/06 2 YA9 15 13 (4) 13/06/06 must be user friendly and person centred that considers the service users health and social care needs holistically and presently. (Previous timescale 30/11/05 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 Refer to Standard YA6 Good Practice Recommendations Further information should be obtained on the service users life history within the initial needs assessment as this would be vital within the development of person centred care plans. Information obtained by care staff when meeting the daily needs of the service user should be written in to the service users individual record in the first instance and could be countersigned by the nurse in charge who may have further information to add. Management should ensure good systems of communication are in place that enables service users to voice a concern without feeling they may not be listened to - this could be linked in to the key-worker role. The responsible individual and manager should give consideration to the timescale of the refurbishment plan to meet the business objectives set out within the refurbishment programme i.e. to provide an environment that continually meets the environmental standard. Within the refurbishment programme the responsible individual and manager should consider the environmental needs of those service users who have dementia. 5 YA39 Management should review the structure of staff meetings to ensure all staff has an opportunity to attend staff meetings and have opportunity to refer to legibly written DS0000062218.V290318.R01.S.doc Version 5.1 Page 27 2 YA6 3 YA22 4 YA24 Ascot Nursing Home minutes. This should ensure staff are fully informed and will promote continuity of care. Ascot Nursing Home DS0000062218.V290318.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA 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. 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