Inspection on 20/04/05 for Ashbourne Residential Home

This inspection was carried out on 20th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Ashbourne Residential Home 29/11/07

Ashbourne Residential Home 18/06/07

Ashbourne Residential Home 24/07/06

Ashbourne Residential Home 11/10/05

Ashbourne Residential Home 20/01/05

Ashbourne Residential Home 12/07/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Ashbourne Residential Home Lightwood Road Dudley West Midlands. DY1 2RS Lead Inspector Cathy Moore Unannounced 20 and 21st April 2005 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 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 Residential Home E55 S24969 Ashbourne V221501 200405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Ashbourne Residential Home Address Lightwood Road Dudley West Midlands. DY1 2RS 01384 242200 01384 242458 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Highfield Care Centres Mrs Ann Gomersall Care Home 38 Category(ies) of Dementia (6) Old Age (32) registration, with number of places Ashbourne Residential Home E55 S24969 Ashbourne V221501 200405 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: Number of residents with dementia 6 No more than 2 persons who are wheelchair users accommodated ( rooms 32/34) 1 resident past or present alcohol dependant A(E) Date of last inspection 20.01.05 Brief Description of the Service: Ashbourne care home is a detached property. It is situated off the main Sedgley to Dudley Road. The home is located in a residential area. It is close to a main bus route and a number of small shops. The home has large gardens to the front and rear and a car parking area. The home is registered with the Commission for Social Care Inspection (CSCI) to provide care to a maximum of 38 residents falling within the category of Old Age. Six of these places at any one time can be offered to older people who have a diagnosis of dementia. Additional conditions of registration apply, these are detailed in the section above. The home comprises of two floors. Communal space is on the ground floor offering a number of different lounges and a dining room. The ground floor houses the reception area, a number of bedrooms, bathing facilities, the main office, the kitchen, laundry and toilets. The first floor accomodates bedrooms, toilets and bathing facilities. The staff group comprises of a manager, deputy manager, seniors and care assistants, a handyperson, an activities co-ordinator, catering, laundry and domestic personnel. Ashbourne Residential Home E55 S24969 Ashbourne V221501 200405 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days from 07.50 hours to 15.50 hours on the first day and 08.55 t0 13.00 hours on the second. The inspection was in part a routine statutory inspection but also in response to an anonymous complaint that was received by the Commission for Social Care inspection which in turn was referred to Dudley Social Services Department. The complaint alleged that there were shortfalls in aspects of care delivery and record keeping. Some elements of the complaint have not been upheld, others upheld and requirements have been to ensure improvement. During the course of the inspection a partial tour of the premises was carried out, four staff members, four residents and one relative were spoken to in detail, a further six residents were spoken to in less detail. Meal times on both days were briefly observed. Residents’ records pertaining to care planning, direct care delivery, risk assessments and other areas were examined. Records relating to health and safety, adult protection, staff recruitment and the premises were also examined. What the service does well: The home at the present time has a full complement of staff, thus ensuring adequate staffing numbers. Observations suggested that relationships and rapport between staff and residents was positive. Residents were very complimentary about the staff and the manager. One resident commented, “the manager is very good, she makes sure that everyone is looked after”, another stated,” I have not been very well, I don’t know what I would have done without the staff”. There were positive comments made about the activities co-ordinator and activities provided. The organisation ensures that all staff receive mandatory training. The home has robust pre-admission processes. The home actively encourages residents to maintain links with their family and friends. The premises overall are of a fairly good standard, although outstanding decoration of bedrooms remains. Two residents bedrooms were viewed, these appeared to be reasonable. One resident commented, ”My bedroom is just how Ashbourne Residential Home E55 S24969 Ashbourne V221501 200405 Stage 4.doc Version 1.20 Page 6 I like it”. Residents are encouraged to bring personal belongings into the home with them to personalise their rooms and make them feel homely. What has improved since the last inspection? What they could do better: The home must improve in many areas of record keeping to ensure that adequate evidence is available in respect of direct care delivery. Security of residents’ files must be ensured at all times. Issues of privacy, dignity, choice and capacity require attention as do processes pertaining to the protection of vulnerable adults. All stakeholders must be actively reminded that the home has a complaints procedure. Measure must be taken to ensure that this complaints procedure is ‘ user friendly’. Factions and possible conflict within the staff team must be explored, managed and eradicated. Formal processes must be implemented to ensure all staff perform as they should across all areas of their job roles. If shortfalls are identified then these must be addressed with staff concerned on an individual basis. The remaining redecoration must be completed. Plans must be made to enhance laundry provision. Ashbourne Residential Home E55 S24969 Ashbourne V221501 200405 Stage 4.doc Version 1.20 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ashbourne Residential Home E55 S24969 Ashbourne V221501 200405 Stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection Ashbourne Residential Home E55 S24969 Ashbourne V221501 200405 Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3,4,5 The home has a robust pre-admission process to ensure that they can meet prospective residents needs before a placement is offered. Residents are given written confirmation of how their needs will be met. All prospective residents and their families are given ample opportunity to visit the home prior to admission enabling them to assess its quality and suitability. EVIDENCE: There was ample, satisfactory documentation available to demonstrate that all prospective residents have a full needs assessment carried out by the manager before they are offered a placement at the home. There was documentary evidence available to demonstrate that all prospective residents are given a written acknowledgement by the home prior to admission, detailing how their needs will be met. The manager confirmed that she now always ensures that prospective residents needs fall within the homes categories of registration before they are offered a placement. There was uncertainty about the primary need of one resident (A.F). Ashbourne Residential Home E55 S24969 Ashbourne V221501 200405 Stage 4.doc Version 1.20 Page 10 Two residents confirmed that they visited the home prior to making a decision about its suitability to meet their needs; this was confirmed by the manager. A brief written account is made by the home pertaining to these introductory/pre-admission visits. Ashbourne Residential Home E55 S24969 Ashbourne V221501 200405 Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 Satisfactory care plans are produced with the involvement of the individual resident. A review of the care plan is not always carried out when changes occur. Although there was strong evidence that personal and health care needs are being met records pertaining to this care are poor. Security of records was concerning. Medication administration systems require some improvement. Feedback from residents confirmed that staff do adhere to the principles of privacy and dignity in general, though more attention to residents right to exercise choice must be given. EVIDENCE: Care plans are produced with the involvement of the individual residents. Seven residents care plans/personal files were examined. Four scrutinised in more detail than others. Care plan content was seen to be mostly satisfactory and there was evidence of resident participation in the care planning process. Care plans are reviewed on a monthly basis. However, a shortfall was identified in that care plans are not always updated as they should be when changes occur. Ashbourne Residential Home E55 S24969 Ashbourne V221501 200405 Stage 4.doc Version 1.20 Page 12 Personal care is provided by the care staff in varying levels, dependant on need. One resident commented “ I don’t need much help, however the staff do help me in and out of the shower to make sure I don’t fall. I can wash myself”. Other residents require full assistance. Thank you cards from relatives of past residents indicated that a good standard of personal care is being provided in their opinion. This confirmed by four residents and four staff interviewed. The standard of record keeping in respect of direct care delivery however, was poor in that there were days when these records had not been completed. An odour was detected in two bedrooms, not in any communal areas. There was evidence that adequate continence aids are available. Records pertaining to daily progress, fluid input, fluid output and change of position were inconsistent. A number were satisfactory, others limited, some not available, either because of omissions or possible sabotage. Record storage was concerning in that there was a lack of security. Resident food consumption records had not been completed since 8.4.05. There was evidence to suggest that all health care services are being accessed either on a regular or as needed basis. A shortfall identified was dentistry for one resident. The main doctor and nurse for the home were seen carrying out a surgery. The medication process was not assessed in full. The home has a contract with a large pharmacy provider organisation. The manager provided evidence to demonstrate that she has requested that all pharmacy audits be unannounced. Staff responsible for medication have received training but not accredited training. One resident self administers his inhalers and cough mixture. There is no lockable facility provided in his room. There had been occasions when medication administration procedures have not been adhered to fully and on occasion, tablets, although given to residents, have not been taken. Four staff interviewed confirmed that (C) and (G) are changed into their night clothes at teatime. This regime was not reflected in the residents’ care plans. Aspects of capacity, choice, orientation, privacy and dignity were discussed with the manager. Observations during the inspection determined that there was a positive rapport and interaction between staff and residents, this was confirmed by residents spoken to. Staff were heard giving residents choices and speaking to them with respect. Two residents asked confirmed satisfaction in respect of staff maintaining their privacy and dignity. Ashbourne Residential Home E55 S24969 Ashbourne V221501 200405 Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13, 14 The home attempts to satisfy residents social and recreational needs. Maintenance of contact with family and friends is encouraged and facilitated. Residents have a degree of choice and control over their lives. EVIDENCE: The home employs an activities co-ordinator who works 20 hours minimum per week. Activities provided are varied, ranging from regular in-house sessions examples of which being discussion groups, painting, drawing, quizzes, computer sessions, trips out of the home and seasonal theme work like the hearts made for Valentines day. One resident commented on the activity provision “ its really good, we do all sorts of things, I like drawing and colouring best”. All residents spoken to were complimentary about the activities co-ordinator and activities provided. Records relating to activity provision and resident participation in these are kept up to date by the activities co-ordinator, however they were seen to be lacking when he is off duty. One resident, commented,” I go out with my nephew every two weeks. I would like it if the staff could take me out more, everyday”. It was identified however, that the staff do take this resident out frequently for a walk or to the local shops. Ashbourne Residential Home E55 S24969 Ashbourne V221501 200405 Stage 4.doc Version 1.20 Page 14 Resident meetings are held on a regular basis. Minutes relating to these meetings were available. The home has a visiting policy. This policy lacks detail of behaviours that would not be tolerated. Visiting times are open and flexible. One resident commented, “my visitors can come and see me anytime they want to”. A relative commented, “I can visit the home whenever I want to, the staff make me feel welcome”. A resident during the course of the inspection went out to a friends house, another has an electric scooter that he goes out on independently. The manager commented that “relatives are regularly invited to meetings and seasonal events, sadly however, not many do attend”. The home has a written voting policy. Arrangements are made to ensure that all residents can vote if they want to either in person or by the postal voting system. Advocacy information is available within the home. All residents bedroom viewed held a number of personal items ranging from ornaments to furniture, televisions and video players. Ashbourne Residential Home E55 S24969 Ashbourne V221501 200405 Stage 4.doc Version 1.20 Page 15 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 Further efforts must be made to raise awareness of and enhance confidence in complaints procedures. The protection of vulnerable adults processes must be further developed. EVIDENCE: The home has a written complaints procedure on display in the reception area. This complaints procedure was in small font. The home caters for the needs of residents who have dementia and poor eyesight, making it difficult for them to read or understand this procedure. One relative commented that she was not aware of the complaints procedure. The four staff questioned were all aware of the complaints procedure. They intimated that if a complaint was made by a relative they would, in the first instance, try and address it personally, or report to a senior or manager. They were aware of the complaint forms in operation. There have been no recorded complaints since the last inspection, other than the one received by the Commission. Staff spoken to were all able to define abusive and neglectful practices. All confirmed that they would not tolerate any form of neglect or abuse and that they would report anything they were not happy with in terms of practice to their manager or higher if required. A number of staff have received abuse awareness training . Ashbourne Residential Home E55 S24969 Ashbourne V221501 200405 Stage 4.doc Version 1.20 Page 16 It was identified that a resident had been ‘hit on the back of the head’ by another resident. This incident had been recorded on both residents files. The manager described this incident as being a ‘tap’. This was discussed in some detail. The home has in place a number of policies and procedures aimed to protect vulnerable adults. These must be revised in terms of appropriateness. Local Authority and Department of Health guidance were available. Ashbourne Residential Home E55 S24969 Ashbourne V221501 200405 Stage 4.doc Version 1.20 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 22,24 The environment must be consistently maintained to ensure safety and comfort for residents. Specialist equipment is generally provided as required. EVIDENCE: It was noted that the home has improved in terms of furnishings and décor over the last eight months. All beds and mattresses have been replaced and co-ordinated bed linen has been provided in some rooms. A number of new carpets have either been fitted or ordered to be fitted. Lounge and communal areas have been redecorated . New chairs have been provided in the lounges. New furniture has been purchased for the reception area. The redecorating programme has come to a halt as the decorators have been allocated elsewhere by the organisation. This leaves the majority of bedrooms still outstanding in respect of redecoration and work partly completed on stairways. Though the handyperson is attempting to progress the redecoration programme, it is a huge task for one person. Ashbourne Residential Home E55 S24969 Ashbourne V221501 200405 Stage 4.doc Version 1.20 Page 18 The laundry is small for the number of residents it caters for. Plans were produced a few years ago for the laundry to be extended. However, this has not been undertaken to date and requires attention. All staff received moving and handling training in March 2005. There was no evidence to suggest that hoists are not used when they should be. Past inspections identified that a resident (D.J) sits in a recliner chair. An outstanding requirement remains for this chair to be assessed to ensure that it is suitable and safe. The home provides a number of aids and adaptations in order to promote safety and independence, examples being hoisting equipment, a passenger lift, ramped access and a call system point in every room. A template has been produced to audit each residents bedroom. To date however, this template has not been completed. Bedrooms viewed appeared comfortable, although as stated previously, require redecoration. All residents spoken to indicated that they are satisfied with their bedrooms. Two bedrooms seen were large and held personal possessions making them feel homely. Personal resident inventories are not all fully completed. A number of residents have commented that the bedroom doors slam shut, which disturbs their sleep at night. Ashbourne Residential Home E55 S24969 Ashbourne V221501 200405 Stage 4.doc Version 1.20 Page 19 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 Numbers of staff are satisfactory to meet resident needs and apart from one minor shortfall recruitment practices support and protect residents well-being. Training is generally adequate but foundation training to the prescribed standard must be developed. EVIDENCE: At the time of the inspection the home had 7 resident vacancies. Staffing numbers appeared to be satisfactory. The home provides dedicated domestic, catering and laundry staff. An activities co-ordinator and handyperson are also employed. There was no suggestion from residents or staff that the present ratios of staff are inadequate. An ongoing concern continues in respect of resident (M.L) who intermittently demonstrates challenging behaviours. There was no evidence of behavioural monitoring patterns to determine if more staff are required at certain times. From speaking to management, it would appear that there is some unsettlement or factions within the staff team. There was evidence that staff meetings are being held regularly. There was no evidence of team building or any other process that may identify individual poor practice or enhance staff relationships. There was no evidence that formal daily staff allocation processes are in operation to enable identification of individual staff who may not be performing as they should, or to identify staggered staff break times. Ashbourne Residential Home E55 S24969 Ashbourne V221501 200405 Stage 4.doc Version 1.20 Page 20 Feedback from residents spoken to in respect of staff attitude and behaviour was positive. One stated “ the staff are very kind and helpful”, another said “staff are all wonderful nothing is too much trouble” There were positive comments about the staff from relatives of residents who were no longer at the home. There was evidence to demonstrate that all staff have either achieved a National Vocational Qualification in care or are working towards this. A number of staff either have level 3 in this award or are working towards this. Overall, sufficient evidence was available to demonstrate that all of the required staff documents and screening checks are being obtained or carried out before they commence employment. The only shortfall identified was no new Criminal records Bureau / Protection Of Vulnerable Adults list check had been carried out when the deputy was promoted from senior. An overall training plan / matrix was seen displayed on the office wall. An individual training plan for each staff member was seen on the staff files viewed. The manager commented that training has been halted due to a change in allocated trainer, although she was hopeful that this would be sorted soon. There was no evidence that a foundation package to the prescribed standard has been produced or implemented. Ashbourne Residential Home E55 S24969 Ashbourne V221501 200405 Stage 4.doc Version 1.20 Page 21 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 Measures are generally taken to promote the health, safety and welfare of residents. EVIDENCE: There was evidence to demonstrate that in-house checks are being maintained in respect of fire fighting and other appliances and that servicing of equipment is being undertaken by external contractors. There was no evidence of an environmental risk assessment. The manager has recently attended an accredited health and safety course, which incorporated risk management. There was evidence to demonstrate that staff have received the required mandatory training or that this is being arranged. Ashbourne Residential Home E55 S24969 Ashbourne V221501 200405 Stage 4.doc Version 1.20 Page 22 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 2 x x 2 x 2 x x STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 x x x x x x x 2 Ashbourne Residential Home E55 S24969 Ashbourne V221501 200405 Stage 4.doc Version 1.20 Page 23 Yes 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 OP4 Regulation 14(1) Requirement The registered manager must seek written confirmation from the doctor in respect of (A.F) to determine if her primary needs are physical due to old age or a mental disorder. If the latter is confirmed then an appropriate variation application must be made to the CSCI. The registered manager must ensure that individual residents care plans are reviewed and up dated when any change occurs. The registered manager must ensure that all care delivery records examples being fluid input/output charts, turn charts are maintained at all times. This to include daily food / fluid intake records in respect of each resident. The registered provider must ensure that the personal care records (for example oral care, hair care) are maintained and up to date at all times. Timescale of 05.02.05 not met. The registered manager must implement a system whereby she can identify which staff Timescale for action 20.05.05 2. OP7 15(2) 21.04.05 3. OP8 17(2) 21.04.05 4. OP8 17(2) 21.04.05 5. OP8 17(2) 01.05.05 Ashbourne Residential Home E55 S24969 Ashbourne V221501 200405 Stage 4.doc Version 1.20 Page 24 6. OP8 17(2) members are responsible if there are shortfalls in respect of record keeping. The registered manager must ensure that only seniors or the manager hold the keys to any care file holding facility and that these are handed over between shifts. Immediate requirement to this effect issued during the inspection. The registered manager must ensure that a suitable lockable facility is utilised for securing care files used in the reception area. Immediate requirement to this effect issued during the inspection. The registered manager must provide the lead inspector with an action plan detailing what action will be taken to prevent care records having to be stored in communal areas. Immediate requirement to this effect issued during the inspection. The registered provider must carry out an investigation to try to identify what happened to the missing care records. A copy of the investigation records and outcomes of this investigation must be forwarded to the lead inspector based at the CSCI office. Immediate requirement to this effect issued during the inspection. Where residents who have capacity are refusing health care services an example being 20.04.05 7. OP8 17(2) 20.04.05 8. OP8 17(2) 25.04.05 9. OP8 17(2) 25.04.05 10. OP8 12(1) 25.05.05 Ashbourne Residential Home E55 S24969 Ashbourne V221501 200405 Stage 4.doc Version 1.20 Page 25 dentistry then this must be documented on their care file. Where residents lack capacity and refuse any health care service then this must be referred to their social worker. Staff members allocated on a shift basis to administer medication must not ask other staff to give medications to residents on their behalf. The staff member allocated to administer medications per shift must ensure that the resident actually takes the medication before they sign the adminstration record. The registered manager must make plans to ensure that all staff responsible for medications receive accredited medication training. The registered manager must ensure that all residents who self medicate are provided with a lockable facility. The registered provider must ensure that no residents are changed into their night clothes in the afternoon and are then left in the communal areas unless it is their expressed choice and reflected in their care plan. The visitors policy must include behaviours that would be unacceptable when visiting the homes and state in what circumstances visitors could be asked to leave. The registered manager must seek the view of Dudley Councils adult protection co-ordinator in respect of the homes abuse, physical intervention and whistle blowing polices. The adult protection co-ordinator can be contacted on 01384 815879. 11. OP9 13(2) 21.04.05 12. OP9 13(2) 21.04.05 13. OP9 13(2) 01.06.05 14. OP9 13(2) 25.05.05 15. OP10 12(3)12(4 ) 21.04.05 16. OP13 13(4) 01.06.05 17. OP18 13(6)(7) 01.06.05 Ashbourne Residential Home E55 S24969 Ashbourne V221501 200405 Stage 4.doc Version 1.20 Page 26 18. OP19 23(2) 19. OP19 23(2) 20. OP22 13(423(1) The registered provider must inform the lead inspector based at the CSCI office of its intentions regarding the finishing of the redecoration programme. The registered provider must inform the CSCI of its intentions in respect of the laundry extension. The registered provider must secure an Occupational Therapist to assess if (D.Js) recliner chair is suitable for his needs. The chair must not be used at any time to restrict the service users movements. 20.05.05 01.06.05 20.05.05 21. OP24 23(2) 22. OP24 23(2) Timescale of 05.03.05 not met. The registered manager must 01.06.05 ensure that a documented audit is carried out in respect of all residents bedrooms against standard 24. The registered provider must 20.05.05 ensure that noise from banging doors etc is minimised during the night time. Timescale of 05.02.05 not met. The registered manager must ensure that all service users belongings are recorded on a personal inventory as per Schedule 4, sections 9 and 10. Timescale of 31.01.05 not met. The registered manager must ensure that the carpets in the bedrooms identified during the inspection as having an odour are replaced. 20.05.05 23. OP24 17(2) 24. OP24 16(2) 21.05.05 25. OP27 17(2)18 (1) If the odour persists then other measures must be taken to manage and eradicate the odour. The registered manager must 01.05.05 ensure that a documented Version 1.20 Page 27 Ashbourne Residential Home E55 S24969 Ashbourne V221501 200405 Stage 4.doc 26. OP27 12(5)18 (1) behavioural monitoring system is implemented , where all behaviours displayed by (M.L) are recorded over every 24 hour period. This to include shouting, threats or any physical displays to staff or residents. If patterns emerge at various times, for example tea time then additional staff at these times must be considered. The registered providers and manager must ensure that systems are introduced to identify conflict, factions,poor practices or possible sabotage within the staff team. Measures must be taken to ensure good personal and professional relationships are developed and maintained. Where issues are identified with indivdual staff then this must be addressed appropriatley on a one to one basis. Staff breaks must be appropriatley staggered. The registered manager must ensure that where staff within the home change position, for example care to senior, senior to deputy then a new CRB/ POVA list check must be applied for. The registered provider and manager must ensure that a foundation programme be developed and implemented to the prescribed standard. 05.05.05 27. OP29 19(1) 21.04.05 28. OP30 18(1)(a) 01.06.05 29. OP38 13(4) Timescale of 01.03.05 not met. The registered provider and 01.06.05 manager must ensure that a qualified person carries out a risk assessment of the premises Timescale of 05.02.05 not met. Version 1.20 Page 28 Ashbourne Residential Home E55 S24969 Ashbourne V221501 200405 Stage 4.doc 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 Good Practice Recommendations Ashbourne Residential Home E55 S24969 Ashbourne V221501 200405 Stage 4.doc Version 1.20 Page 29 Commission for Social Care Inspection West Point Mucklow Office Park Mucklow Hill Halesowen. B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ashbourne Residential Home E55 S24969 Ashbourne V221501 200405 Stage 4.doc Version 1.20 Page 30 - 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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