Inspection on 05/11/08 for Ashbourne

This inspection was carried out on 5th November 2008.

CSCI found this care home to be providing an Adequate service.

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

Ashbourne 06/05/08

Ashbourne 25/10/07

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 06/02/2009.

CARE HOMES FOR OLDER PEOPLE Ashbourne 12 Neale Avenue Kettering Northamptonshire NN16 9HE Lead Inspector Sally Snelson Unannounced Inspection 5th November 2008 09:30 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 Ashbourne DS0000070317.V372747.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. Ashbourne DS0000070317.V372747.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashbourne Address 12 Neale Avenue Kettering Northamptonshire NN16 9HE 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) 01536 513363 ashbourne@msaadacare.com Msaada Care Limited Manager post vacant Care Home 18 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (17) of places Ashbourne DS0000070317.V372747.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered persons may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission are within the following categories: Old Age - Code OP. 2. Dementia - Code DE(E) (maximum 1). The maximum number of service users who can be accommodated is 18. 6th May 2008 Date of last inspection Brief Description of the Service: Ashbourne is situated on a residential street close to the edge of town with street parking to the front. The building is a large detached care home covering two floors, with an office on the first floor and storage space in the cellar. There is a passenger lift to take people who use the service who might not be able to manage the stairs to the upper floor. To the rear of the property is an enclosed garden with a patio area. Ashbourne is owned by Msaada a company who have several other services in the area. Fees: At the time of this inspection fees ranged between £400-£500 per week depending on a variety of factors. Ashbourne DS0000070317.V372747.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection was carried out in accordance with the Commission for Social Care Inspection’s (CSCI) policy and methodologies, which requires review of the key standards for the provision of a care home for older people that takes account of residents’ views and information received about the service since the last inspection. Information from the home, through written evidence in the form of an Annual Quality Assurance Assessment (AQAA) (this was requested earlier in the year for a previous inspection) has also been used to assess the outcomes within each standard. Evidence used and judgements made within the main body of the report include information from this visit. Also included in the report is the outcome from a random inspection visit undertaken on 11th August 2008. Sally Snelson undertook this inspection of Ashbourne. It was the second key inspection of the year, was unannounced, and took place from 09.30am on 5th November 2008. Jenny Short, the manager, was present throughout. Feedback was given throughout the inspection, and at the end to the manager and the deputy manager. During the inspection the care of two people who use the service (residents) was case tracked in detail. This involved reading their records and comparing what was documented to what was provided. In addition to sampling files, people who lived at the home, visitors, and staff were spoken to, and their opinions sought. Any comments received from staff or residents about their views of the home, plus all the information gathered on the day and at visits since the last key inspection was used to form a judgement about the service. The inspector would like to thank all those involved in the inspection for their input and support. Ashbourne DS0000070317.V372747.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The manager had changed again since the last inspection and the staff team were beginning to consolidate. The manager and the deputy manager were working closely together and complemented each other. People were being assessed for admission within the present registration categories. People were being provided with information about the home in the form of the service user guide and the statement of purpose, setting out Ashbourne’s aims and objectives and the services and facilities on offer. Every resident had a copy of their contract with Ashbourne, or a copy of the terms and conditions of residence as appropriate. The controlled drug cabinet had been moved and was in a more convenient position. However the cabinet still needed to be replaced to meet the regulation. A system for reviewing the quality of service had been introduced but it needed to be built upon. All members of staff working at the home were receiving regular formal supervision. Resident’s files should included care plans relating to death and dying, which included resident’s and their family’s wishes. Ashbourne DS0000070317.V372747.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. Ashbourne DS0000070317.V372747.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 Ashbourne DS0000070317.V372747.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. People who use this service experience good quality outcomes in this area. The manager was aware of the need to ensure that prospective residents were thoroughly assessed prior to admission. This ensured that the home, and the staff team, could meet the physical and social needs of a person. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: At the random inspection on 11th August 2008 we found that a copy of the Service users guide was available in the entrance hall of the home and copies had been issued to people using the service and/or their relatives/advocates. The manager was aware of the need to ensure the management arrangements for the home were altered in these documents to reflect her position as the manager. Ashbourne DS0000070317.V372747.R01.S.doc Version 5.2 Page 10 At the last inspection three people using the service were case tracked and it was found that their files contained signed copies of the contract, at this inspection both files sampled included completed contracts. There had been no new admissions to the home since the last inspection so we were not able to fully assess how staff would ensure that Ashbourne could meet the needs of a prospective user. However the manager was able to tell us how she would assess a prospective resident and what she would be assessing. The home was registered for 18 service users but the manager did not envisage two of the double rooms being used for shared occupancy in the future. At the time of the inspection Ashbourne did not offer intermediate care but would consider people for respite care if a bed were available. Ashbourne DS0000070317.V372747.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): 7,8,9,10,11. People who use this service experience adequate quality outcomes in this area. Care plans had been written but they needed to be more organised, more detailed, and reviewed monthly to ensure that there was written documentation to support the care that was being provided. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: During this inspection we tracked the care of two people using the service. This meant that we looked at how their care needs were documented in the care plans, and if the care delivered reflected the documentation. At the last key inspection in May 2008 it was reported that care plans ‘remain poor and fail to direct staff on how to meet needs.’ At the random inspection Ashbourne DS0000070317.V372747.R01.S.doc Version 5.2 Page 12 in August it was reported ‘Care plans have been developed and contain clear information on how identified needs are to be met by the care staff. A range of risk assessments to meet personal and health care needs supports these plans. End of life plans are now included within the care plans. Care plans are being reviewed with full involvement of people using the service and their relatives/advocates.’ The improvements made between May and August now needs to be built upon and show that they can be sustained. For example the care plans need to be more organised and the information recorded under the correct heading so that staff can use them to ensure that they deliver the care correctly. We suggested that it may be helpful for a plan for every activity of daily living to be written for each resident, but the manager must choose a system that suits her and the staff team. We noted that staff had worked to make some necessary changes to the care planning documentation, but had not been able to review the plans monthly. The deputy told us that because of the workload staff had chosen to leave the plans of those people whose care needs did not change, for more than the month stated in the National Minimum Standards. This is not acceptable, and if staff are unable to indicate that a care plan has been reviewed at least monthly then staffing levels need to be considered. However we did see that care plans had been reviewed and altered where care needs had changed recently. As with the care plans the risk assessments needed to be kept under review. Staff must also indicate when making assessments that when a change is recorded that this is acted upon. For example, significant weight losses or increases should prompt more regular monitoring, and possible extra intervention. At the time of the inspection none of the people using the service had pressure sores. Staff were aware of the need to encourage people to move about as much as possible and to drink plenty. Daily notes were written and included key information, to improve this needed to refer back to the care plans. We looked at the medication charts and procedures for the people whose care we tracked. The home had recently changed their pharmacy provider and staff had received some additional training from the pharmacist. This training mainly deals with administering using the pre-packed monitored dosage system. Records indicated that the Medication Administration Charts (MAR) had been completed correctly and omission codes used as necessary. However we were unable to reconcile those medications that were prescribed to be given ‘as needed’, and were not part of the pre-packed monitored dosage system, because the charts supplied by the pharmacy did not have a system to Ashbourne DS0000070317.V372747.R01.S.doc Version 5.2 Page 13 record the number of tablets, or the amount of medication, carried forward from the month before. Normally we would count the number of signatures and count the tablets left in the home to ensure that these reconciled. Since the last key inspection the cabinet that stored controlled drugs (CD) had been moved so that staff did not have to leave the main are of the home and have easier access to the medication. The cabinet however needs to meet the new regulations for the storage of controlled drugs as since 2007 a CD cabinet must:•be a metal cupboard of specified gauge •have a specified double locking mechanism •fixed to a solid wall or a wall that has a steel plate mounted behind it •fixed with either Rawl or Rag bolts. The manager told us that a suitable cabinet had been delivered but as it would not fit easily in the space of the original it had not been fitted. Staff were seen to be positive in their approach to people using the service. They were polite and enabled people to choose. Locks had been fitted to all bedrooms to ensure privacy and safety. The locks could be overridden by the master keys in an emergency. End of life plans were now included within the care plans, but again these could be built upon and indicate who should be called if a resident suddenly became poorly and if they want to be called at any time or just during the day. Any end of life wishes recorded must be supported by a capacity assessment. Ashbourne DS0000070317.V372747.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. People who use this service experience adequate quality outcomes in this area. Staff had identified the social activities that would please and stimulate the people using the service, these must be introduced and built upon. Meals were freshly prepared, healthy and there was a choice available. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: At a recent residents meeting the manager discussed with the people using the service what they would like to do in the way of activities and what they used to enjoy doing. As a result staff were looking at the possibility of supporting two of the residents to attend a church, and for a public house where some residents could go for an occasional meal. One resident who used to be a gardener expressed an interest in doing some gardening, and another offered to make the Christmas wreath for the front door. All these suggestions need to be set in place in order to provide appropriate stimulation for the people Ashbourne DS0000070317.V372747.R01.S.doc Version 5.2 Page 15 living at the home. The staff must also consider those people using the service with dementia, and impaired vision and hearing, when planning an activity programme. On the day of the inspection a professional was providing a motivation class that consisted of encouraging people to use their memory, some chair exercises and singing. Most of the residents joined in this activity and all who did appeared to enjoy it, and benefit from it. The manager had also arranged for entertainers and various choirs to provide entertainment for Christmas. There was a computer that residents could use, but there was a problem with it at the time of the inspection. It was hoped that it could be used by, or on behalf of, at least two of the residents to help them keep in contact with family who were away. We noted that friends and relatives were welcomed into the home and made a drink on arrival. They could meet with the relative in private if they wished either in the resident’s own bedroom or in the small lounge referred to as the parlour. We believed that residents were encouraged and made decisions about how their care was provided. One resident had chosen to stay in bed all day recently and staff acknowledged that this was his choice and took his meals to his room. The home employed a cook to work Monday to Friday and a second for the weekend. We saw people being offered the choice between fish pie and chicken burgers for lunch followed by fresh oranges in jelly. The choice of meals is limited to what can be cooked in the small oven. This is discussed in detail in the environmental section of this report. People were asked to make choices in advance of their meal, and we did discuss with the manager the possibility of offering a plated choice at the mealtime, or photo cards for those people with dementia. People using the service confirmed that they could have their breakfast when they wanted and we noted that drinks were readily available. The home had signed up to a local initiative to encourage drinking regularly and had water machines situated around the home. At the time of the inspection the cook managed to meet the requirements of diabetic and vegetarian residents. Ashbourne DS0000070317.V372747.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 People who use this service experience good quality outcomes in this area. The complaints procedure and staff understanding of safeguarding people kept the people living at Ashbourne safe. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: This area of the report had not given cause for concern in the past and there had been no significant changes. The new manager had been a registered manager in the past. She demonstrated an understanding of handling complaints and safeguarding vulnerable adults (SOVA). The complaints procedure was available in the home, and as part of the Statement of Purpose and the Service Users Guide. The procedure referred to a number of contacts including the manager, the director of Msaada, an advocate, parents in partnership and us. Parents in partnership is an advocacy organisation for parents of young people with a learning disability, and not appropriate for Ashbourne residents. It was also noted that our address was given as an office in Leicester, that is now closed. Ashbourne DS0000070317.V372747.R01.S.doc Version 5.2 Page 17 All of the staff had had recently had SOVA training and the manager was aware of the need to keep a log of any complaints and how they were investigated. Ashbourne DS0000070317.V372747.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): 19,26 People who use this service experience poor quality outcomes in this area. The home was clean and tidy but there were a number of areas that needed to be improved to make it homely and safe. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The cleaners kept the home clean and tidy and free from any offensive odours but there was a need for some refurbishment and redecoration. For example many of the bedrooms did not have covers over the radiators. This must be attended to immediately. Following the inspection we asked the provider to tell us how they proposed to do this and by when by issuing an immediate requirement letter. Ashbourne DS0000070317.V372747.R01.S.doc Version 5.2 Page 19 Some carpets in the home had been replaced, this meant that the pattern and colours of carpets changed around the home, which is known to be difficult for people with dementia, other carpets had big patterns on them, again confusing for those with dementia. Some carpets were worn, particularly on the staircase, which could become dangerous if allowed to continue. There were curtain rails in the hallway, but no curtains, which made the hallway appear like a corridor. In one bathroom there were no curtains or blinds and the room was overlooked. This compromised the dignity of the resident’s. Many of the areas of the home were not suitable for wheelchairs and we witnessed staff having to tip wheelchairs to negotiate doorways. The manager was aware that she could not admit a resident who used a wheelchair to the home, but a resident may need to use a wheelchair at any time during their stay. The manager had a long list of maintenance jobs that needed attending to and had been told by the providers that they had instructed a contractor to work on some of these. The grass had recently been cut but we were told that throughout the summer months the garden had not been used. This was disappointing to some of the residents who remembered good times in the garden including garden parties. The kitchen needed to be upgraded. The cook was expected to prepare meals for up to 16 residents on one small cooker that had a main and top oven. Therefore the choice of menu had to be determined by the oven space. The home had no dedicated sleep-in room and at the time of the inspection staff were using one of the empty bedrooms as a sleep-in room. Because of the layout of the home dirty laundry had to be taken via the lounge to the laundry room. We noted that laundry was not bagged as it was carried through the communal areas and could be the cause of cross infection. The front door was opened from the outside using a keypad. The number was known by staff and visitors, and could compromise the resident’s safety if used incorrectly. It was not acceptable for the exit from the home to be via a code, if the code was not available to those who did not need to be restricted. This practice did not comply with fire regulations, as the code was not available to everyone within the home, for example occasional visitors. During the August inspection it was established that the call bell system was faulty in two rooms. An immediate requirement was been made for the system to be repaired and this was complied with within an acceptable timescale. Ashbourne DS0000070317.V372747.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 People who use this service experience adequate quality outcomes in this area. Recruitment practices at the home protected the people who used the service. However staff training still needed to be broadened to meet the assessed needs of the residents. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Staff files were checked and contained all the required checks for staff. Some staff did not have a photograph of the staff member to confirm their identity. A new member of the staff team spoken with during the inspection confirmed that all checks had been completed prior to them starting the job and that they were completing an induction programme before doing any additional training. All the staff had completed, or were in the process of completing, NVQ qualification. This included the domestic staff, which is commendable. As already mentioned all staff had completed safeguarding training and medication training (provided by the supplying pharmacist). Two staff were Ashbourne DS0000070317.V372747.R01.S.doc Version 5.2 Page 21 booked to attend a dementia training workshop and it was proposed that they cascaded their learning out to other staff. It is essential that the training programme included mandatory training and specialist training to ensure that the staff team have the collective experience and qualifications to meet the needs of the residents. The manager was aware of the staff training gaps and used supervision sessions to discuss training needs. All staff must have a minimum of three paid days training a year. Staff rotas confirmed that there was three staff on duty during the day, and that the manager was not included in the number unless she was recorded as working a shift. However despite it being recorded that at least two people using the service required the assistance of two staff at night, there was only one waking staff on duty. A sleep-in person who could be called in an emergency supported the night carer. This must be reviewed and risk assessed and the reasoning documented if the manager feels it is correct to continue with these levels. Ashbourne DS0000070317.V372747.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): 31,33,35,36,38 People who use this service experience adequate quality outcomes in this area. The manager must ensure that the regulations are met and people are kept safe under her leadership. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager had been in post for about eight weeks. She had been a registered manager in the past, and was intending to apply to register as the manager of Ashbourne. Her recent management experience had not been with Ashbourne DS0000070317.V372747.R01.S.doc Version 5.2 Page 23 older people and she was aware of the need to familiarise herself with the National Minimum standards for older people. The manager worked well with the deputy manager and they appeared to complement each other. Staff appeared happy under their leadership. The previous manager had introduced a quality assurance system and had sent out questionnaires to service users and their relatives. This needed to be evaluated, a report written and the outcomes used to influence future plans for the home. Quality assurance must then become a regular part of the homes ethos to fully meet this standard. The manager had introduced staff meetings and residents meetings, but again these needed to be held regularly and to influence the running of the home. The home held small amounts of money on behalf of residents. The money held reconciled to the balances recorded, but because some receipts, (such as the receipt from the hairdresser) was a block receipt it was not possible to see an audit trial for the money. We were concerned that some people’s balance was in the negative and that money was only available when the manager was on duty. Since the last inspection the manager and the deputy had re-introduced supervision sessions. Staff confirmed that they were given the opportunity to discuss personal and work related problems and to explore training needs. Health and safety checks were carried out but again not at the frequency required. The manager must ensure that fire alarms are tested weekly and that there are regular checks of water temperatures and medication storage temperatures. We noted that while unsupervised by staff a resident walked into the kitchen and the laundry areas and could have put themselves at risk as there were no locks on the doors for times when staff were carrying out care duties elsewhere in the home. The duty rotas should include the surname of the staff member and indicate who is the shift leader. Ashbourne DS0000070317.V372747.R01.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 3 3 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X X X X X X 1 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 2 2 x 1 Ashbourne DS0000070317.V372747.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15(1) Requirement Care plans must contain more detail so as to instruct staff in how resident’s specific needs are to be met. This requirement is remade However it is apparent that there has been some work towards meeting it. The care plans and risk assessments must be kept under review at least monthly. The controlled drug cabinet must meet the regulations. This requirement is remade. The manager confirmed that a cabinet had been delivered but was not in use. Activities within the home must ensure that they are meeting the needs of all people who use the service. This requirement is remade. However it is apparent that there has been some work towards meeting it. All radiators must be covered. DS0000070317.V372747.R01.S.doc Timescale for action 31/12/08 2 3 OP7 OP9 15(1) 13(2) 31/12/08 01/12/08 4 OP12 16 31/12/08 5 OP19 23 20/11/08 Page 26 Ashbourne Version 5.2 6 7 OP19 OP26 23 23 An immediate requirement was left. The identified refurbishments must be carried out. Systems must be in place to prevent the spread of infection. This refers to unbagged soiled laundry being carried through communal areas. 31/12/08 01/12/08 8 OP27 18(1)(a) There must be evidence that there are sufficient staff on duty at all times. All health and safety checks must be carried out at the required intervals 01/12/08 9 OP38 23(4) 20/11/08 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 Refer to Standard OP1 OP11 OP15 OP29 OP31 Good Practice Recommendations The home’s Statement of Purpose and Service users Guide should be kept up-to-date. The end of life plans should include additional information about who is to be called and when it a person using the service becomes poorly. The menu should not have to be determined by the size of the cooker. Recruitment files should provide proof of identity The acting manager needs to make a timely application to become the registered manager. The provider needs to ensure that this is acted upon. This is to ensure that the home is not being run in breach of the regulations. The system for reviewing the quality of Ashbourne service and improving it (A Quality Assurance system) needs to be built upon. The money held by the home on behalf of people using the service must include the receipts for all expenditures. DS0000070317.V372747.R01.S.doc Version 5.2 Page 27 6 7 OP33 OP35 Ashbourne 8 OP36 All members of staff working at Ashbourne should continue to receive regular formal supervision, to ensure that they are each supervised a minimum of six times a year. Ashbourne DS0000070317.V372747.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Ashbourne DS0000070317.V372747.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. Re-publishing this information is in breach of the terms of use of that website. 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