Inspection on 20/07/07 for Ascot Nursing Home

This inspection was carried out on 20th July 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ascot Nursing Home 08/08/06

Ascot Nursing Home 15/12/05

Ascot Nursing Home 25/07/05

Ascot Nursing Home 14/02/05

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

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

CARE HOMES FOR OLDER PEOPLE Ascot Nursing Home 19-21 The Crescent Linthorpe Middlesbrough TS5 6SG Lead Inspector Katherine Acheson Key Unannounced Inspection 20th and 25th July 2007 10:30 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 Ascot Nursing Home DS0000061594.V343743.R02.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. Ascot Nursing Home DS0000061594.V343743.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ascot Nursing Home Address 19-21 The Crescent Linthorpe Middlesbrough TS5 6SG 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) 01642 825283 01642 850412 Mr George Dixon Mrs Susan Olive Ellis, Mrs Angela Catherine Allick, Mr Michael Dixon Ms Angela Catherine Allick Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (0), Physical disability (0) of places Ascot Nursing Home DS0000061594.V343743.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home can admit a maximum of five younger people with a Physical Disability (PD). The home can admit a maximum of two people under 60 years of age. Date of last inspection 16th January 2007 Brief Description of the Service: Ascot Nursing Home is registered to provide personal and nursing care to thirty-two older people. The home is a three-storey building providing single and double room accommodation. There are thirty single bedrooms, five of which have ensuite facilities, which comprise of a toilet and sink. There is one double bedroom with ensuite facilities. All bedrooms in the home environment meet space requirements of National Minimum Standards. There is a passenger lift giving access to upper floors. There is one large lounge, an adjoining quiet lounge and a dining room. Externally there is an enclosed garden area with patio for residents to enjoy. A small amount of car parking space is available at the front of the home for visitors. The home is situated on The Crescent in Linthorpe and as such is close to shops and amenities. The cost of care at the time of the inspection visit ranged from £355 to £499 per week. Ascot Nursing Home DS0000061594.V343743.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection of the home was carried out over two days the 20th and 25th of July 2007. On the first day of the inspection the Inspector arrived unannounced. The Manager of the home was aware of the second day of the inspection. On the 20th July 2007 the Inspector arrived at 10:30am and left at 4:45pm. On the 25th July 2007 the Inspector arrived at 11:50am and left at 3:45pm. The reason for the inspection was to see how good a job the home does in meeting the National Minimum Standards set by the government for Care Homes. Eight residents, one relative, one care assistant, the cook and a trained nurse were spoken to during the inspection. A lengthy discussion also took place with the Manager. Numerous records including care plans, menus, quality assurance, complaints and staff recruitment and training records were examined. The Inspector walked around the home with the Manager. Before the inspection fifteen relative comment cards and fifteen resident comment cards were sent out to the home to give to residents and families asking them to complete and comment on the care that is received at the home. Ten relative comment cards and seven resident comment cards were received. Comments can be read in the main body of the report. Requirements identified at the last inspection in January 2007 were re-visited. The details of any issues identified at this inspection requiring action are to be found at the back of this report. What the service does well: The home is well run and a good standard of care is provided to residents. Residents are happy and their needs are catered for. Food provided is appetizing and enjoyable, activities and outings are stimulating and fulfilling. Residents and relative comments made included, “Lovely surroundings, owners have home lovely, friendly, skilled, caring staff” “On visiting the home we have always noticed a warm and caring atmosphere” Ascot Nursing Home DS0000061594.V343743.R02.S.doc Version 5.2 Page 6 “The support and care given is exceptionally good” What has improved since the last inspection? 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. Ascot Nursing Home DS0000061594.V343743.R02.S.doc Version 5.2 Page 7 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 Ascot Nursing Home DS0000061594.V343743.R02.S.doc Version 5.2 Page 8 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): Standards assessed 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessments of prospective residents are carried out to ensure that the home can meet their needs. EVIDENCE: The Manager said that before going into the home residents are assessed by a Social Worker or nurse. Staff at the home then carry out their own pre-admission assessment either visiting the person in their own home or at hospital to ensure that the needs of the resident can be met at Ascot. Two residents files were looked at during the visit, both of which contained an assessment of needs and evidence of personal choice. Ascot Nursing Home DS0000061594.V343743.R02.S.doc Version 5.2 Page 9 Ascot Nursing Home does not provide intermediate care so standard 6 is not applicable. Ascot Nursing Home DS0000061594.V343743.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards assessed 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a good standard of care, residents living at the home are happy. Some improvements are needed in respect of medication systems/practice to help to prevent/reduce errors. EVIDENCE: Two plans of care were looked at during this visit. Residents files examined contained an assessment of the resident, which identified any problems with day-to-day activities of daily living and any medical conditions. Following assessment of the resident, staff at the home develop a plan of care for each individual problem, however, this appears to be more of a task list rather than detailing personal care required. An example of this being, one care plan described a resident as needing help to wash and dress, but this plan Ascot Nursing Home DS0000061594.V343743.R02.S.doc Version 5.2 Page 11 of care did not detail what the resident could do for themselves or assistance required from staff. Of the two care plans examined one had been updated and evaluated on a monthly basis, the other had not. Risk assessments were evident on residents files, however again were insufficiently detailed. One file examined identified a resident as being at risk of falls. This risk assessment did not identify why the resident was at risk or detail any specific intervention to reduce or prevent falls. Risk assessments were not evaluated to confirm effectiveness. Care plans showed evidence of regular visits from G.P’s, District Nurses and Dentists. One comment card received stated that “Concerned at long periods between chiropodist visits. Feet need more frequent attention to remain comfortable” Eight residents and one relative were spoken to during the inspection comments made included, “It’s fantastic” “I like it her the staff are pretty good” “They are all so friendly” “It’s alright if you can’t manage in your own home then this is the next best thing” Comment cards received from residents and relatives stated “The home is very sensitive to the varying needs of my mother” “Staff are extremely kind and caring” Residents spoken to confirmed that their dignity and privacy was respected. During the inspection arrangements for receiving, storing, administering, recording and disposing of resident’s medication were observed and examined. The Manager has reviewed the homes medication policy since last inspection. This policy/procedure was looked at briefly during the visit. A discussion took place with the Manager regarding the need for further detail within the policies/procedures so that staff follow safe practice when handling medication. Medication was stored appropriately. Ascot Nursing Home DS0000061594.V343743.R02.S.doc Version 5.2 Page 12 Nurses working at the home are responsible for giving residents their medication. During the visit a medication audit of one of the residents files sampled during the inspection was carried out. The Medication Administration chart (MAR chart) had been completed with signatures from staff to confirm medication had been administered, however on counting the stock balance this did not match up with medication ordered, received, administered and remaining in the home. The Manager said that she would look into this as matter of urgency. The Manager said that the home support those residents who are able to administer their own medication. At the time of the visit there were two residents who were responsible for their own medication. Lockable storage is provided to store medication within the resident’s bedroom. The Manager said that residents are responsible for administering their own medication have a risk assessment in place. Examination of records identified that risk assessments are in place, however are insufficiently detailed. The risk assessment or plan of care did not identify how the residents fitness to administer medication had been determined or identify any agreed safety precautions like limiting the number of medications provided at any one time or carrying out counts on medication at agreed times with the resident. Ascot Nursing Home DS0000061594.V343743.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards assessed 11, 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate and enjoyable activities do take place at the home. Residents are able to exercise choice and visitors are made to feel welcome. Food provided is varied, appetizing and appealing and provides residents with a wholesome balanced diet. EVIDENCE: The home employs an Activity Co-ordinator to plan, arrange and take part in resident activities. The Activity Co-ordinator works five hours a week, two and a half hours, twice a week. At other times care staff organize activities. Activities taking place include bingo, dominoes, jigsaws, cards, and arts and crafts. At the time of the inspection residents were busy preparing for the homes annual summer fete. Some residents were glass painting Ascot Nursing Home DS0000061594.V343743.R02.S.doc Version 5.2 Page 14 Residents spoke of entertainers coming into the home to sing. On the first day of the inspection residents were going to a 1940’s event organised by a local radio station. Residents on return spoke of 1940’s dress and how they had enjoyed the singing and dancing. A small group of residents had also recently been to see “The good old days” at The Little Theatre. A bird table with nuts is situated outside near the dining room window in resident view. Residents were heard talking about the squirrel that visits on a regular basis. Contact with family and friends is encouraged and that visitors are made to feel welcome at any time. The Manager said that two residents are supported to go out of the home independently. They both like to go into Linthorpe Village and to the Local Post Office. Residents and relatives spoken to said, and comment cards received stated, “Five to six weeks ago entertainers came into the home, everyone was dancing” “I like my television, I like to join in the bingo and really enjoy a sing-a-long” “The care home responds well to the needs of patients as individuals, but fosters a real sense of community with numerous activities to which residents and relatives are invited. Relatives are very much included as part of the team” The home supports residents to practice their religion. The Manager spoke of a number of residents who are practicing Catholics, a special minister visits the home to give communion to residents. One other service user goes to church on a Sunday with their family. Residents interviewed spoke of flexibility in routine and freedom of choice. The lunchtime of residents was observed. Mealtime was relaxing with residents enjoying the food provided. The lunchtime menu on the day was fish, chips and mushy peas. Pudding was sponge and custard or yoghurt. Residents spoken to said, and comment cards received stated “Food is marvellous all fresh and beautiful” “The food suits me, you have a choice” “Lots of variety” Ascot Nursing Home DS0000061594.V343743.R02.S.doc Version 5.2 Page 15 “Alternatives are given if I don’t like the food on the menu” Ascot Nursing Home DS0000061594.V343743.R02.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): Standards assessed 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives are able to express their concerns. Staff are aware of procedures to follow if abuse is suspected which helps to protect residents. EVIDENCE: The home has a complaint procedure. This procedure should be updated to inform residents/relatives of their right to complain to any commissioning authorities such as the Primary Care Trust or Social Services. The complaint procedure within the statement of purpose/service user guide should also to be updated to include such information. Residents spoken to during the inspection said that they would feel comfortable in raising and concern or making a complaint to the staff or management of the home. The home keeps a record of complaints. There have not been any complaints made to the home or the Commission for Social Care Inspection in the last twelve months. Ascot Nursing Home DS0000061594.V343743.R02.S.doc Version 5.2 Page 17 The Manager said that the home has an adult protection policy that details action that staff should take if abuse is suspected. She also said that staff at the home receive training on induction and on a regular basis thereafter. Appropriate action has been taken by the home in respect of the two adult protection referrals made in the last twelve months. Ascot Nursing Home DS0000061594.V343743.R02.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): Standards assessed 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home is good providing the people who live there with and attractive, homely and comfortable place to live. EVIDENCE: The Inspector walked around the home with the Manager. In general communal areas are well maintained with appropriate furnishings throughout. There is a large lounge, a small adjoining quiet lounge and a dining room. Lounge and dining areas are newly painted and carpeted. A number of lounge chairs have been purchased since last inspection. On the first day of the inspection it was noticed that the fire in the main lounge area of the home was not guarded to ensure safety of residents. The Manager Ascot Nursing Home DS0000061594.V343743.R02.S.doc Version 5.2 Page 19 advised that the fire was not used, as the heating system in the home was sufficient. As the fire was not used the Manager felt that rather than guard the focal point of the room and spoil the look that she would arrange for the fire to be disabled. On return to the home for the second day of the inspection the Manager said that this had been carried out. Bedrooms looked at during the visit were personalized and contained appropriate furniture. The Manager said that a number of bedrooms are to be refurbished over the coming months. A walk round of the home identified exposed hot water pipes in bathrooms. On return to the home for the second day of the inspection the Manager advised that the handyman had commenced the process of boxing pipes in to ensure safety of residents. It was also identified that long nurse call leads hanging from ceilings could pose a risk to residents. Again on return to the home the Manager had taken action to ensure safety of residents by carrying out a risk assessment to determine if any residents could be at risk from the long cords. The Manager said that she would continue to review residents and carry out risk assessments at regular intervals. Appropriate laundry facilities are in place. On the day of the inspection the home was observed to be clean and odour free. Ascot Nursing Home DS0000061594.V343743.R02.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): Standards assessed 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff at the home are trained, skilled and in sufficient numbers to meet the needs of people living at the home, however inadequate pre employment checks do not help to ensure safety of residents. EVIDENCE: At the time of the inspection there were twenty-seven residents living at the home. The homes duty rota showed that there were four or five care assistants on duty between the hours of 8:00am and 8:00pm and two care assistants on duty at night. There is one trained nurse on during the day and night. The Manager of the home, who is also nurse, is supernumerary and as such works in addition to the staff numbers above. Ascot Nursing Home is one home in a small group of homes who trade of the Illumina Group. The Manager is also the Operations Director for the group. The Manager works a number of days a week at Ascot and other days carries out other Managerial duties associated with the other homes. The duty rota at Ascot did not identify working hours for the Manager. Ascot Nursing Home DS0000061594.V343743.R02.S.doc Version 5.2 Page 21 Residents spoken to and comment cards received stated that in general sufficient staff were on duty to meet residents needs. The home has worked extremely hard to assist care staff to achieve an NVQ level 2 in care. 75 of care staff working at the home have now achieved an NVQ level 2 in care. Two staff files were examined during the inspection. Files contained the required documents including, a photograph, proof of identity, two references one being from the last employer. Of the two staff files examined, one contained evidence that the Manager had received a satisfactory Criminal Record Bureau Check before the staff member started work, the other did not. The Manager said that this staff member had worked supervised until checks had been received. The Manager was informed that this was not acceptable and that appropriate checks must be received prior to start of work. Records were available to confirm that new staff receive induction training. Records were available to confirm that training is provided to staff working at the home, this included, Moving and handling, fire, abuse training, medication awareness and infection control. Ascot Nursing Home DS0000061594.V343743.R02.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): Standards assessed 31,33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Quality assurance systems are in place to ensure that the home is run in the best interest of residents. In general the home is well run with the health and safety of residents being promoted, however, irregular tests of the fire alarm system and failure to follow Health and safety guidelines to carry out weekly water temperatures could put residents at risk. EVIDENCE: The Manager is a general nurse who has a diploma in nursing and a recently achieved a BSC Honours degree. The Manager has many years of experience of working with older people. In January 2007 she commenced the Registered Ascot Nursing Home DS0000061594.V343743.R02.S.doc Version 5.2 Page 23 Managers Award and hopes to achieve the management qualification within the next three to six months. Residents and the one relative spoken to during the inspection and comment cards received spoke highly of the Manager and staff team. Comments made included, “A well directed and administered establishment. Praise worthy in every respect” “The Manager is very good” “They do everything to a high standard” Quality assurance and quality monitoring practices are in place. Surveys are sent out to residents on a yearly basis to see if they are happy with the home and care that is provided. The results are published and displayed on a notice board in the entrance to the home. The home looks after small amounts of money belonging to some residents. Appropriate records of transactions are kept. The hairdresser visits the home regularly and some residents pay for this service directly from their pocket money account, however the hairdresser does not issue a receipt. Although records are kept by the home of money taken from the account it would be a good practice to get a receipt. Records were examined to confirm that the Gas boilers and fire extinguishers had been serviced within the last year. The Manager said that a rolling programme of servicing of appliances and equipment is in place. Water temperatures in resident areas are taken and recorded on a monthly basis it is suggested that the Registered Person give consideration to the Health and Safety Guidelines to monitor bath and shower water temperatures weekly. Records examined highlighted a number of bath and shower water temperatures that were too cool; this was pointed out at the time of the inspection. The Manager said that weekly tests of the fire alarm system are carried out, however records showed that initially tests did appear to be carried out weekly, however appear to be more on a monthly basis. The Manager said that she would take immediate action to address the situation. Ascot Nursing Home DS0000061594.V343743.R02.S.doc Version 5.2 Page 24 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Ascot Nursing Home DS0000061594.V343743.R02.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 OP7 Regulation 13, 14, 15 • Requirement Care plans must be developed further to ensure that they are specific to the resident. This will help to ensure that the resident gets the help that they need Care plans must be reviewed/updated on a monthly basis or more often if required Risk assessments must be developed further to ensure that they identify the individual risk to the resident and specific intervention required to reduce/prevent identified risk Risk assessments must be reviewed and evaluated on a regular basis to confirm effectiveness The Registered Person must ensure safe systems are in place for handling resident’s medication. A clear audit trail of medication ordered, received, administered, Timescale for action 30/08/07 • • • 2 OP9 13 • 20/07/07 Ascot Nursing Home DS0000061594.V343743.R02.S.doc Version 5.2 Page 26 3 OP29 13 4 5 OP31 OP38 9 23 remaining in the home and returned must be available and match up to ensure safety of residents. • The Registered Person must ensure risk assessments for those residents administering their own medication are sufficiently detailed to ensure resident safety. The Registered Person must ensure that appropriate employment checks are carried out and received prior to the commencement of employment to ensure safety of residents The Manager must achieve an NVQ level 4 in Management or equivalent • The Registered Person must ensure that regular checks of the fire alarm system are carried out • The Registered Person must address the problem of shower and bath water temperatures that are too cold 20/07/07 31/01/08 20/07/07 Ascot Nursing Home DS0000061594.V343743.R02.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. Refer to Standard OP9 Good Practice Recommendations The registered person should ensure that all policies and procedures are appropriate for practice in the home, up to date, and reviewed regularly so that all staff understand how to handle and administer medicines safely. The Complaints policy/procedure should be updated to include information of resident’s rights to complain to commissioning agencies such as Social Services and the Primary Care Trust. The homes statement of purpose and service user guide should also be updated to reflect such information The homes duty rota should include the Managers daily input and scheduled working hours The Manager should obtain a receipt from the hairdresser when paying for this service The Registered Person should give consideration to the Health and Safety Executive Guidelines to monitor bath and shower water temperatures weekly 2. OP16 3. 4. 5. OP27 OP35 OP38 Ascot Nursing Home DS0000061594.V343743.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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 Ascot Nursing Home DS0000061594.V343743.R02.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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