Inspection on 01/05/08 for Ashbourne House Nursing Home

This inspection was carried out on 1st May 2008.

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

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

Other inspections for this house

Ashbourne House Nursing Home 12/05/10

Ashbourne House Nursing Home 25/01/10

Ashbourne House Nursing Home 29/10/09

Ashbourne House Nursing Home 21/05/07

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Ashbourne House Nursing Home 376-378 Rochdale Road Middleton Manchester Lancashire M24 2QQ Lead Inspector Bernard Tracey Unannounced Inspection 08:15a 1st May 2008 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 House Nursing Home DS0000068938.V361955.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 House Nursing Home DS0000068938.V361955.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashbourne House Nursing Home Address 376-378 Rochdale Road Middleton Manchester Lancashire M24 2QQ 0161 643 2060 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) Silverdale Care Homes Ltd Vacant Care Home 29 Category(ies) of Dementia - over 65 years of age (16), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (2), Old age, not falling within any other category (13), Physical disability (1) Ashbourne House Nursing Home DS0000068938.V361955.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 29 service users to include: *Up to 13 service users in the category of OP (Old age not falling within any other category); *Up to 16 service users in the category of DE (E) (Dementia over 65 years of age); *Up to 2 service users in the category of MD (E) Mental Disorder over 65 years of age); *Up to 1 service user in the category of PD (Physical disability). 21st May 2007 Date of last inspection Brief Description of the Service: Ashbourne House Nursing Home is a converted and extended home located a short distance from the centre of Middleton, owned by Silverdale Care Homes Limited. The home is registered to care for up to 29 people with personal care needs, nursing needs and those with dementia. Accommodation is provided over two floors, the majority of it on the ground floor. Part of the first floor of the building is not available to residents because of structural defects that are being repaired but repairs have not yet been completed. The range of fees at the time of our key inspection was £347.71 to £460.32. Additional charges are made for Chiropody and Hairdressing Ashbourne House Nursing Home DS0000068938.V361955.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 2 stars. This means the people who use this service experience Good quality outcomes. We (the Commission of Social Care Inspection) undertook a key inspection, which included an unannounced visit to the home. The staff at the home did not know the visit was going to take place. The manager was asked to fill in a questionnaire, called an Annual Quality Assurance Assessment (AQAA), telling us what they thought they did well, what they need to do better and what they have improved upon. Where appropriate, these comments have been included in the report. We spent six and three quarter hours at the home over one day. During this time, we looked at care and medicine records to ensure that health and care needs were met and also studied how information was given to people before they decided to move into the home. A tour of the building was undertaken and time was spent looking at records regarding safety in the home. We also examined files that contained information about how the staff were recruited for their jobs, as well as records about staff training. We spent time speaking to three residents, as well as speaking to four staff, the manager a district nurse, Community Psychiatric Nurse and the owner of the home. In January 2008 we undertook a random inspection which looked at the issues we were concerned about from the last key inspection. References to the findings of that inspection have been included in this report. We have received one complaint about the service, which was found to be unsubstantiated. What the service does well: The admission arrangements for new people moving into the home were thorough and include detailed assessments of the person’s specific care and behavioural needs. Ashbourne House Nursing Home DS0000068938.V361955.R01.S.doc Version 5.2 Page 6 We saw that people were being cared for in an individual way, according to their own needs and wishes. Staff spent a lot of time with people and demonstrated a good understanding of their needs. Comments received included: “I like it at the home”; “Nice people”; “A good home”. Care files seen were organised, easy to read and provided good detail with regard to individual care needs. Through discussion and observation it was evident that residents were treated respectfully and the home ensures good standards of privacy and dignity. The social care staff used this information to help them plan suitable activities and entertainment for people. The kitchen staff prepared good quality meals and knew what people liked and needed. Staff were able to access a good amount of training and a high number of care staff had a National Vocational Qualification (NVQ) in care. What has improved since the last inspection? What they could do better: We have asked that the information about the home (Statement of Purpose) is updated, on two previous occasions, but this still has not been done. This results in people coming to the home not having up to date and accurate information to help them decide whether this home is right for them. Ashbourne House Nursing Home DS0000068938.V361955.R01.S.doc Version 5.2 Page 7 There is still a large amount of work outstanding in respect of making the home a pleasant and well maintained environment. The work includes decoration and some remedial work, including level flooring and carpeting. The sluice needs to be tiled and any disinfectants or other chemicals be kept locked in it. Recruitment practices are not robust to protect the residents. New staff must not commence employment prior to two references being obtained. Good practice recommendations are made in the main report to implement best practice and improve the overall service. 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 House Nursing Home DS0000068938.V361955.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 House Nursing Home DS0000068938.V361955.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 & 3 (Standard 6 does not apply) Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The statement of purpose and the residents’ guide do not give clear relevant information about the home. Assessments are carried out prior to admission to ensure the staff can meet the needs of the residents. EVIDENCE: At the last inspection, a requirement was made that the Statement of Purpose and Service User Guide must be reviewed and updated in order to ensure they contain all the information as set out in the standards. This would then enable new people to know what to expect if they decide to become residents. Ashbourne House Nursing Home DS0000068938.V361955.R01.S.doc Version 5.2 Page 10 We examined the Statement of Purpose and found that it had not been updated since our last visit. The document does not reflect the new company that has taken over the home and did not contain all the information that is required, as set out in the Care Homes Regulations, (Schedule 1). There were many omissions and the provider must now amend this document so as to ensure it includes all the required information. The Service User Guide had not been reviewed and updated. It does not include terms and conditions of residence, fees payable, arrangements in place for charging and paying for any additional services, reference to the most recent inspection report and the complaints procedure. The previous manager’s details were still referred to in the document. This document must also contain all the required information as set out in the Care Home Regulations. When these documents are completed, copies must be forwarded to us within the timescale given at the end of the report. The manager undertakes a full needs assessment with the resident, their relative and with the relevant health care professional where possible. We examined the documentation for three residents, including the most recent admission and found that an assessment had been carried out and recorded good detail of current health and social care needs to enable staff to provide the care and support required. Key areas include personal hygiene, mobility, diet, continence, sleep, communication, risk of falls and social care. Basic care needs, such as optical, dental, foot care and hearing, are assessed, as they are important to the care of an older person. A resident said, “I like being here, everyone is very kind indeed”. Standard 6 was not assessed, as intermediate care is not provided. Ashbourne House Nursing Home DS0000068938.V361955.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. There is a clear and detailed care planning system in place that provides the staff with the information needed to meet the needs of the residents. EVIDENCE: Further to previous requirements, a lot of work had been done to update and improve the care records. We looked in detail at the care plans and risk assessments for thee people, including the most recent admission to the home. The plans contained good details about people’s specific care needs and included a good amount of social history and background information on the person’s interests and life achievements. There were clear guidelines for staff on how to care for individual people and how to manage their health care needs and any known habits. Ashbourne House Nursing Home DS0000068938.V361955.R01.S.doc Version 5.2 Page 12 The majority of care plans and risk assessments had been updated in the last month, although some still needed doing. We acknowledge the good progress staff have made in improving the care plan documentation. The manager and nurses spoken to were knowledgeable about the specific needs of the people they cared for. Nurses confirmed that they had been allocated time each week away from their duties, to work on updating care plans, and this had enabled them to bring the majority of records up to standard. We saw that people looked well cared for and received a good amount of positive attention from staff. Three residents’ care files were examined as part of this process. The care files were easy to read and the information clearly recorded nursing care and social needs. Care plans seen were based upon individual need with information on how staff need to give the appropriate standard of care and support. Key areas include: mobility, risk of falls, sleep, eating and drinking, communication, sight, dental care, medication usage, mental state, personal safety and risk, social involvement and personal well being. Care plans seen had, in the main, been reviewed monthly and changes made where needed. There was evidence of the resident and/or relatives’ agreement and consent to ensure they were aware of the care provision. Supporting care documents include: risk assessments for skin, moving and handling, and nutrition. The risk assessments address safety issues whilst aiming for better quality of life for the residents with the support of the staff. The new manager has introduced a system whereby staff sign a day book to evidence personal care, such as bathing and other personal support; daily record sheets are completed at the end of each shift to report on the care and support given. There was evidence of good liaison with healthcare professionals, such as the doctor, district nurses and Community Psychiatric Nurses. The Intermediate Care Nurse and a District Nurse were visiting on the day of our inspection, both were able to confirm that improvements to the care planning and review of care had been made. Since the last inspection the manager and staff had made a number of improvements to the way medicines were managed in the care home. A new policy was in place and staff were seen to be working within the detail of the policy. Medicines records had generally improved and it was possible to trace the amount of medicines received into the care home, and to account for what had been administered and what had been discarded. Ashbourne House Nursing Home DS0000068938.V361955.R01.S.doc Version 5.2 Page 13 Since the last inspection, the manager had introduced a comprehensive medicine audit tool that had recently been completed in relation to the Controlled Drugs held in the home. Further to this, the manager was in the process of accessing a medicines training course to ensure that all the nurses’ knowledge and practice were up to standard. Ashbourne House Nursing Home DS0000068938.V361955.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): Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Social activities are creative and provide daily variation and interest for people living in the home. The dietary needs of the residents were well catered for with a balanced and varied selection of food being served. EVIDENCE: The residents’ involvement in social activities varies greatly according to their abilities and nursing needs. Some of the residents spoken to preferred to stay in their own bedrooms and enjoyed reading, listening to music and watching television. Importance is attached to ensuring that residents are given the opportunity for stimulation through leisure and recreational activities. Residents who wish to, participate in the day’s activities and it is ensured that individual attention is given in this as well as the more organised group programme. There is a dedicated member of staff who arranges the activities in the home. Special occasions are celebrated and, at the time of the visit, photographs of the celebration of St Valentine’s day and St George’s day were evident. There was a programme of visiting entertainers and activities. Ashbourne House Nursing Home DS0000068938.V361955.R01.S.doc Version 5.2 Page 15 More attention should be placed on setting the tables for each meal. We saw several placemats that were marked, tablecloths were not present on all tables and no resident was offered a napkin. The lunchtime meal was taken in a relaxed environment, with staff and residents regularly interacting with each other. Time was taken for residents to eat their meals and staff would ask each person if had they finished or would like a further helping, before removing the plate. Staff were observed to assist those residents requiring help in a caring, sensitive and unhurried way, gently encouraging the resident to continue with their meal until they had finished eating. Menus were nutritious and balanced and included a good variety of meat, fish, fresh vegetables and fruit. The manager confirmed that, should a resident request something that was not on the menu, alternative meals were available. Residents said they were asked in the morning what they would like from the choices for lunch and tea and all felt this was a good idea. There were many compliments and expressed satisfaction by residents in respect of the food offered by the home. Comments included: “Lovely food”; “The girls and cook always ask us what we want”. Ashbourne House Nursing Home DS0000068938.V361955.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): Standard 16 &18 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents have confidence that their concerns will be dealt with. policies and procedures are in place to protect the residents. Abuse EVIDENCE: The home’s complaint procedure is on display and residents and relatives interviewed were satisfied with all arrangements in the home but were aware of how to make a complaint if needed. A staff member said, “If a resident wanted to make a complaint, I would go to the nurse in charge”. The complaint log was seen and no complaints have been received. The home has a procedure in place for dealing with allegations of abuse. The management and staff spoken to had a good understanding of the procedures to be followed in the event of any allegations or suspicion of abuse or neglect. Staff are encouraged to attend appropriate training course to help them understand all areas that could be seen as abuse. It was evident that residents were happy with the service provision and felt safe and supported. Ashbourne House Nursing Home DS0000068938.V361955.R01.S.doc Version 5.2 Page 17 Staff receive adult protection training and have access to an abuse policy and also the local guide for the protection of vulnerable adults. Staff interviewed were able to describe the concept of abuse and, when incidents need external input, who they talk to. Ashbourne House Nursing Home DS0000068938.V361955.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, 25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Whilst some improvements have been made, the environment is neither homely or wholly safe for residents to live in. EVIDENCE: The majority of the structural work on the ground floor of the home, which was being undertaken at the time of the last key inspection, had been completed. Some new flooring had been fitted, some carpets replaced and structural work to doors and windows had been completed. There are, however, deficiencies still evident that we pointed out to the owner on our visit. Ashbourne House Nursing Home DS0000068938.V361955.R01.S.doc Version 5.2 Page 19 The ground floor sluice was in need of complete refurbishment; walls need tiling, the taps above the sluice were loose and free-standing, the flooring needs replacing, the hole in the ceiling needs covering. When the remedial work is completed, the manager must ensure that the chemicals and cleaning products are stored safely in a locked cabinet. The door to the sluice must be kept locked at all times. Refurbishment of the bathrooms and toilets on the ground floor has still not taken place. We saw that bath surrounds were loose, the flooring needs replacing and the rooms require decorating. The double toilets near to the lounge need decorating and the flooring replaced. The general tidiness of this room was poor, with cupboards not being used for the purpose of storing the equipment, e.g., paper towels, gloves and clinical waste bags that were evident. The dining room and corridors at the far end of the building need decorating. The owner is proposing some further structural changes to accommodate more storage facilities in this area; when he has decided on the best way to progress he should write to us detailing the plans before starting the work. A trip hazard was identified on the ground floor lounge exit opposite the kitchen where there was quite a significant dip in the floorboards between the lounge and corridor. We discussed this with the Registered Provider and the manager during our visit and stressed that remedial action must be taken to address this. On the first floor, the works were still ongoing in respect of the refurbishment of bedrooms. Whilst only two residents had bedrooms on this level, concerns were raised with the manager in respect of potential health and safety risks in this area. She said that the two people were dependent upon staff to assist them with their mobility and would be unable to access these areas without support. In order to ensure their safety, environmental risk assessments must be written and implemented for these people whilst this work is ongoing. The manager said the requirements made in the fire report from the Greater Manchester Fire Service, that had taken place on 13th February 2007, had been implemented. The GMC fire officer was said to have returned to inspect the work and confirmed satisfaction. The manager has been asked to conduct a full environmental audit and submit a maintenance and development plan to the Commission in response to the deficits noted in our inspection. Ashbourne House Nursing Home DS0000068938.V361955.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The numbers and skill mix of staff were sufficient to meet the needs of the residents. EVIDENCE: Examination of the duty rotas and a discussion with staff and residents indicated that, generally, there were sufficient staff to meet the care needs of the residents. There are a minimum four staff in the morning and a minimum four staff in the afternoon. For residents who require nursing care, 24-hour care continues to be provided by qualified nurses. Staff members interviewed were able to demonstrate that they had a clear understanding of their role and responsibilities within the home. They were able to describe their role within the team, to support residents, as well as their specific responsibilities as key worker to the residents. Residents felt that the staff are supportive and skilled in their role. Descriptions of staff members included “always prompt when you need help” and “they can’t do enough for you”. Ashbourne House Nursing Home DS0000068938.V361955.R01.S.doc Version 5.2 Page 21 The personnel files of three members of staff were examined at the inspection. Two files contained the required information to meet this standard but one file did not have the required two references needed before someone is confirmed in employment in the home. Newly recruited staff are confirmed in post only following a satisfactory CRB and POVA disclosure. In the case of Registered Nurses, confirmation of registration and qualifications with the Nursing and Midwifery Council is made. The manager has implemented a staff training and development programme in order to ensure the staff fulfil the aims of the home and meet the needs of the residents. Members of staff receive a comprehensive induction programme within six weeks of their appointment, which includes the principles of care, safe working practices and the particular needs of older people. Copies of the induction programme were evident in the staff files inspected. Staff interviewed on the inspection confirmed that they were given the opportunity to receive training, particularly in moving and handling, infection control and basic food hygiene. Ashbourne House Nursing Home DS0000068938.V361955.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): Standard 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The newly appointed manager is in the process of improving the day-to-day management within the home to ensure the overall quality of the service for people will be improved and maintained. The home is well managed and run in the best interests of residents. EVIDENCE: Ashbourne House has been without a registered manager for some time. The previous manager did make an application to be registered with the Commission but has since resigned. A new manager has been appointed who is a qualified nurse who has many years’ experience in caring for residents and has a recognised management qualification. Ashbourne House Nursing Home DS0000068938.V361955.R01.S.doc Version 5.2 Page 23 Throughout the visit we were able to observe the professional, capable and approachable manner in which the manager undertook her role when dealing with residents, staff and visitors. At the time of our visit the manager had been in post for four weeks. Residents, visiting professionals and staff spoke well of the management team and the care and support that they give. Staff said that since the manager had been appointed she provided a clear sense of leadership. The manager had developed a number of audit tools to enable her to keep a continuous check on the quality of care plans, medicines management and infection control practices. Only the medicines audit had actually been completed at the time of this visit. Staff said they were well supervised on a day-to-day basis and we found that the manager spent a lot of time “on the shop floor” to see how staff were working. It was previously recommended that a more formal system of supervision would help to identify individual training and personal development needs. In response to this, the manager has introduced a supervision system for senior staff, which she intends to follow up with more regular formal supervision for all of the staff. A selection of safety contracts for equipment and services in the home were viewed. The gas, lift and fire prevention certificates were in date. The electrical certificate could not be located; it was agreed that a copy of the certificate would be forwarded to the Commission to ensure the ongoing protection of the residents. The policies and procedures in the home ensure that the health, safety and welfare of the residents and staff are promoted and protected. Ashbourne House Nursing Home DS0000068938.V361955.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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 2 X X X X X 2 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Ashbourne House Nursing Home DS0000068938.V361955.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP19 Regulation 13(4)(a) Requirement The uneven surface between the lounge door and the corridor to the kitchen must be filled in so that residents will not trip and fall. The missing tiles on the sluice walls must be replaced, so as to lessen the risk of infections spreading. A programme to detail the maintenance and the renewal or replacement of fabrics and the timescale for completing the decoration of the home must be forwarded to the Commission of Social Care Inspection. The sluice must be tidy and kept clean so as to lessen the risk of infections spreading. (Previous timescale of 29/02/08 not met). The cold-water tap in the sluice must be in working order and the extractor fan must be repaired so that the health and safety of staff is not at risk. (Previous timescale of 29/02/08 not met). DS0000068938.V361955.R01.S.doc Timescale for action 30/06/08 2 OP19 23 (2) (b) 30/06/08 3 OP19 23 (2) 30/06/08 4 OP26 13(3) 12/06/08 5 OP26 13(4) 30/06/08 Ashbourne House Nursing Home Version 5.2 Page 26 6 OP29 19 (1)(c) Schedule 2 8 7 OP31 8 OP33 26 The registered person must obtain two written references for new staff employed to protect the residents An application for a registered manager must be submitted to the Commission of Social Care Inspection so that they are assured it is being managed by someone competent to do so. The Registered Provider must provide a written report of an unannounced visit to the home each month and forward a copy of the report to the Commission of Social Care Inspection 12/06/08 30/07/08 30/06/08 Ashbourne House Nursing Home DS0000068938.V361955.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP1 Good Practice Recommendations The Statement of Purpose and Service User Guide should be reviewed and updated in order to ensure they contain all the information as set out in the standards. This will then enable new people to know what to expect if they decide to become residents. Copies of both documents must be sent to us so that we can update our files. It is recommended that the re-decoration of the home and replacement of worn carpets be continued as planned. It is recommended that the refurbishment and redecoration of all toilets and bathrooms be continued as planned. A quality assurance and monitoring system should be set up so that the owner and manager can measure outcomes for the people living at the home. Staff should receive supervision and an annual appraisal. All policies and procedures should be reviewed and, where necessary, updated. An electrical safety certificate should be obtained to demonstrate that the wiring in the building is sound. A copy of the electrical certificate for the service should be forwarded to Commission. 2 3 4 5 6 7 8 OP19 OP19 OP33 OP36 OP38 OP38 OP38 Ashbourne House Nursing Home DS0000068938.V361955.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Manchester Local Office Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ 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 House Nursing Home DS0000068938.V361955.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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