Inspection on 24/07/06 for Ashbourne Residential Home

This inspection was carried out on 24th July 2006.

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 11/10/05

Ashbourne Residential Home 20/04/05

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 Mrs Cathy Moore Unannounced Inspection 24th July 2006 07:15 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 Residential Home DS0000024969.V302388.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 Residential Home DS0000024969.V302388.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashbourne Residential Home Address Lightwood Road Dudley West Midlands DY1 2RS 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) 01384 242200 01384 242458 Southern Cross Care Centres Limited Mrs Ann Margaret Gomersall Care Home 38 Category(ies) of Dementia - over 65 years of age (12), Old age, registration, with number not falling within any other category (26) of places Ashbourne Residential Home DS0000024969.V302388.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. That no more than 2 persons who are wheelchair users are accommodated (rooms 30/34) within the additional 10 places. That the additional staffing resources be secured prior to any service user being admitted. One service user in the category of OP may also be A(E). This will remain until such time that the current service users placement is terminated. One service user with sensory impairment elderly SI(E) to be admitted. This will remain until such time that the current service users placement is terminated. 11/10/06 Date of last inspection 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. Since the last inspection the home has refurbished one unit in the home to care for residents who have dementia. The home is now registered with the Commission for Social Care Inspection (CSCI) to provide care to Twenty-six residents falling within the category of Old Age and twelve residents who have a diagnosis of dementia. 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 accommodates 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. Weekly fees for this home range from £ 343- £461. There are additional costs as follows; chiropodist £8 and hairdresser –set £5, perm £15 and cut £5. Ashbourne Residential Home DS0000024969.V302388.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one inspector on one day between 07.15 and 19.00 hours. Information was gained before the inspection by asking the manager to complete a questionnaire. Questionnaires were sent for residents to complete unfortunately, only 4 of these were completed and returned. Four residents, were chosen to ‘case track’ this process includes examining records relating to their care and well being examples being; their assessment of need documents, care plan, and daily notes. Three staff files were examined to look at their recruitment situations and training. Nine residents’ and five staff were spoken to. The manager was involved in the whole inspection process. The premises were randomly assessed which included viewing four bedrooms, bathrooms, toilets, communal areas, the laundry, kitchen and gardens. Breakfast and lunch times were observed as were some routines during the day. Medication management and systems were assessed. Records concerning health and safety and residents finances were examined. What the service does well: The home is owned by an organisation who has numerous other homes and is therefore able to offer support and guidance and has extensive experience of care home service delivery. The manager has been in post for a number of years offering stability to the home. The home offers a good activity service to residents’. One activities coordinator is employed 30 hours per week another provides activities during the afternoon on the dementia care unit. Activity provision includes a range of different things including; shopping to local shops, art and craft activities and themed nights. Recently a ‘pirates night’ was held. The home actively encourages residents’ to maintain contact with family and friends. Visiting times are open and flexible. Staff observed worked hard. They spoke to residents politely and gave them choices. Staff have a good understanding of the wishes of the residents’ in their care. Over 55 of the care staff have achieved N.V.Q level 2 or above in care. Staff receive one to one supervision regularly. Positive comments received about the home included;” The staff are lovely”. “ The staff are wonderful”. “ I am happy”. “ I enjoy all my meals”. Ashbourne Residential Home DS0000024969.V302388.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Health and personal care needs to be improved in terms of delivery and record keeping. Medication systems revealed major shortfalls where for example; the night medication for one resident was not available. There were gaps in medication records where staff had not signed to confirm that medication had been given. Staffing levels are a concern. Three staff for twenty-two residents on one unit and two staff for twelve residents with dementia on the other unit is not sufficient. Staffing on both units needs to be increased by one during the mornings at least. The atmosphere of the home felt very tense and strained this could have been because of the inspection or because of the shortage of staff. Infection control processes are concerning with dirty mop heads left to soak in dirty water. Communal bar soap in bathrooms and a lack of disposable gloves available within the home. The laundry is in need of a major refurbishment. Dining room chairs were seen to be stained as was the carpet in the lounge. It is a real concern that although Southern Cross the owners of the home assured the Commission during the registration process that the dementia unit garden would be ready for spring 2006 to date it is not safe or usable for the residents. During this summer in the warm weather residents have not been able to go in the garden unless escorted by staff and then usage is very limited. The rest of the garden has not been tended as it should have been to the point that a neighbour complained Ashbourne Residential Home DS0000024969.V302388.R01.S.doc Version 5.2 Page 7 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. Ashbourne Residential Home DS0000024969.V302388.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 Residential Home DS0000024969.V302388.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4. The overall outcome for this group of standards is judged to be good. No resident moves into the home without having had his/her needs assessed or being assured that these will be met. EVIDENCE: Of the four resident questionnaires received it is positive that all four confirmed that they had adequate information provided to enable them to make the decision that the home would be suitable for them. Documentation was available on each resident file assessed to demonstrate that an assessment of need had been carried out. A letter was on file addressed to each resident confirming that the home could meet their needs. It is positive that assessment details and information had been obtained for each resident from their social worker or funding authority. Ashbourne Residential Home DS0000024969.V302388.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. The overall outcome for this group of standards is judged to be poor. Care plans are deemed to be adequate. Personal and health care issues require improvement to ensure that all needs are being met. Medication systems have major shortfalls which could pose as a risk to residents. EVIDENCE: It is positive that a care plan was on file for each resident case tracked. These were of a good standard and are reviewed regularly. Evidence was available to demonstrate that residents or their relatives are consulted about their care plans. Diabetic care plans should be expanded to detail signs of hypo and hyper glycaemia so that staff are aware of these and what they should do. There was good evidence of risk assessment concerning tissue viability, falls and nutritional assessment. Weight recording particularly on admission was confusing and deemed not to be accurate. For example a weight of 79kgs had been recorded for one resident on 18 May 06 then on 25 May 06 the weight for the same resident had been recorded as 88 kgs. For another resident their Ashbourne Residential Home DS0000024969.V302388.R01.S.doc Version 5.2 Page 11 weight had been recorded as 44kg on admission yet another sheet for the same day it had been recorded as 52 kgs. Generally records are maintained of professional visits for example the nurse, doctor and optician however, staff are not consistently recording chiropody visits. There was some confusion about personal care delivery recording. For two residents on the official forms there were no records to demonstrate that a bath or shower had been given for the month of June 2006. Records of oral care were also lacking. The home was short staffed on the day of the inspection. It was disappointing that two residents’ observed had untidy hair and dirty nails. Staff defended these observations by saying; “ We have not had time to do the finishing touches today”. This is not acceptable residents must receive the care that they require at all times. The assessment of the medication systems was disappointing. Although a previous requirement had been made one resident had run out of his night medication. This situation could have been easily avoided if the person recording the incoming medication had been more vigilant. It was clear that insufficient medication for this person had been received. At least three initial gaps were missing from medication records. Temazepam for one resident had not been signed for in the controlled drug register. On the medication record for one resident it stated Vitamin B12 injections, yet there was no evidence that these have been given or that clarification had been obtained from the doctor whether or not the injection is needed. Similarly, one resident medication chart states Ferrous Sulphate yet there was no stock available or evidence that this tablet is being given. Staff confirmed that they are not complying with medication key hand over processes. It is positive that the manager has secured medication training for staff. Yet this has not yet been completed. It is positive that the preferred form of address has been determined for each resident and that this is recorded on their records and used. Staff observed and heard during the inspection were polite and respectful to the residents’. Toilet and bathroom doors shut when in use. At the present time all bedrooms are being used as single rooms only this enhances resident privacy and dignity. Ashbourne Residential Home DS0000024969.V302388.R01.S.doc Version 5.2 Page 12 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 the following standard(s): 12,13,14,15. The overall outcome for this group of standards is judged to be adequate. The home must ensure that daily routines are based on residents’ needs and choices. Activity provision is good. Residents are encouraged to maintain contact with family and friends. Residents are helped to exercise some choice and control over their lives. Staff availability at meal times, particularly breakfast must be improved. EVIDENCE: On entering the home at 07.15 hours it was observed that ten residents were up and dressed in the ‘residential’ lounge. Four of these were asleep in their chairs. There was mixed views from staff about whether there is an expectation that the night staff get so many residents up in the morning. Although this was not confirmed it was not fully denied either by all staff. The home must ensure that daily routines at all times are based on resident needs not resources available. It is extremely positive that the home has two activity co-ordinators. One is employed 30 hours per week the other works afternoons. Activities offered include art and craft work, trips and outings and themed events such as the recent ‘pirate’ evening. Residents’ are offered the opportunity to visit local Ashbourne Residential Home DS0000024969.V302388.R01.S.doc Version 5.2 Page 13 shops on a regular basis. One resident said; “ I go out everyday, I love to go out”. Feedback from the four resident questionnaires received was surprising as the home has two activity co-ordinators. One resident confirmed that, ‘there are activities arranged that they can take part in, always, two usually and one sometimes. One resident did say, “ I love the activities, baking cakes is my favourite”. Residents’ bedrooms viewed held a range pf personal effects from photos and ornaments to televisions. Information concerning external advocacy services was on display in the home. The home has produced new menus to be placed on the tables. One for main meals, one for supper and one for breakfast. To date no pictorial formats have been produced to aid the understanding of residents who have dementia. Breakfast and lunch were observed. For breakfast the residents can have what they want from a range of cereals or hot options. One resident had a full cooked breakfast which looked very nice. Another had porridge and really enjoyed this. The food at lunch time was appetising, was attractively presented and smelt delicious. The choice was boiled bacon or fish in parsley sauce, vegetables and potatoes followed by treacle sponge and custard. One resident said, “ I love my meals”. Another said, the meal was ”Very nice”. One male resident chose a beef salad instead of the set menu. Two concerns were identified during the meals. At breakfast three dependant residents were left in their easy chairs. The inspector was told that “ they wait for their breakfast until care staff are free to lift and feed them”. This is totally unacceptable. Staff should be available at all times to ensure there are sufficient at meal times so residents’ do not have to wait. A requirement was made following the last inspection to this effect yet it was the same during this inspection. Further one resident refused her lunch, although she was encouraged without success to eat it no alternative was offered. Food and drink consumption charts are used within the home although it was observed that these are not consistently completed. One area lacking is the recording of supper. Ashbourne Residential Home DS0000024969.V302388.R01.S.doc Version 5.2 Page 14 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 the following standard(s): 16,18 The overall outcome for this group of standards is judged to be adequate. Residents’ and relatives are confident that their complaints will be listened to and acted upon. Fine tuning of processes is required to ensure that residents are protected from abuse. EVIDENCE: The home has a written complaints procedure in place. An additional simple complaints procedure, part pictorial has been produced to try and aid the understanding of residents who have dementia. Two complaints have been received by the home since the last inspection. One from a resident concerning an agency staff member, the other from a neighbour concerning the garden. It was positive that both complainants were responded to in writing and both are now happy with the outcomes. Three of the four completed resident questionnaires received confirmed that they know who to speak to if they are not happy, one said that they usually did. Two of the four confirmed that they know how to make a complaint two said that they usually did which is fairly positive. One allegation of abuse has been made since the last inspection concerning a ‘ slapping incident’. The manager of the home reported the incident correctly to Social Services and the Commission. The outcome of this was that there was insufficient evidence to upheld the allegation. Ashbourne Residential Home DS0000024969.V302388.R01.S.doc Version 5.2 Page 15 The manager has made available to staff the homes’ prevention of abuse policies. Training has been booked for July and August 2006. The one shortfall is that training arranged and staff knowledge may not fully cover Dudley MBC multi-agency protection procedures, which must be activated if an allegation or incident occurs. It is clear that the manager is fully aware of these procedures but other staff must be also for when the manager is on holiday. Ashbourne Residential Home DS0000024969.V302388.R01.S.doc Version 5.2 Page 16 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 the following standard(s): 19, 20,21,25,26. The overall outcome for this group of standards is judged to be poor. The home has received maintenance work over the last year, however, work is still required. Areas of concern are the inadequate number of toilet sin the residential unit, the lack of safe outdoor/garden space for the dementia unit, the lack of adequate ventilation/cooling in the dementia unit lounge/ dining area and shortfalls concerning infection control. EVIDENCE: Five bedrooms have been redecorated since the last inspection. Other decorating work has also been undertaken which is very positive. However, work is still needed. A number of seals on window panes have failed. Window frames have seen better days and need replacing. The carpet on the first floor of the residential unit is well past its best. The home since the last inspection has refurbished one unit and offers dedicated dementia care. This unit is secure and relatively well designed in terms of orientation. Ashbourne Residential Home DS0000024969.V302388.R01.S.doc Version 5.2 Page 17 It is extremely concerning and disappointing that although assurances were given by the homes ownership that the garden area for the dementia unit would be ready for use by spring 2006 this has not happened. The garden is unsafe and unfit for purpose. Residents’ not able to access the garden unless supervised resulting in them being confined indoors during the hot whether we have had of late. The other gardens have been neglected to the extent that a neighbour has complained and the manager concerned about grass fire. It is further concerning that since the dementia unit has been in operation the total toilets available on the ground floor for the residential unit is two which includes the staff/visitors toilet which has no call alarm system. It must be acknowledged that this shortfall has been highlighted and plans have been made for two toilets to be provided which is still insufficient for 22 residents’. The dementia unit particularly the lounge/dining room was extremely hot at the time of the inspection to the point that it could pose as a health threat to residents’, there were no fans or other cooling mechanisms in place. Whilst it is positive that the organisation has moved the laundry appliances to make more space and that metal shelving and a new tumble dryer have been provided the laundry is still of an unacceptable standard. The floor was replaced before the machines were moved resulting in places where there is no floor covering. Further the second sink has been removed leaving no sink for washing delicate hand washed clothing items. The laundry is in need of a redecoration, retiling and a good clean. Dining room chairs were seen to be stained, two with a brown substance. Waste bins in one toilet in particular was extremely odorous as was one bedroom. The residential lounge carpet was stained in a number of places. Bar soap was seen in at least two bathrooms and one toilet along with shampoo and talc bottles all of these could present as an infection hazard. Suggestion was made that there are insufficient protective clothing particularly disposable gloves for staff which is a concern. Mop control leaves a lot to be desired. Mops and buckets seen were not labelled for the areas they are to be used in. Mop heads were seen left soaking in dirty water and were dirty, even the one in the kitchen. There was no evidence that the mop heads are being cleaned by disinfectant cycles daily. Feedback from the four resident questionnaires confirmed that ‘ The home is fresh and clean’ – always. The manager confirmed that a weekend cleaner has now been appointed. One staff member said; “ The cleanliness of the home has improved, it was really bad before”. Ashbourne Residential Home DS0000024969.V302388.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. The overall outcome for this group of standards is judged to be adequate. Residents needs are not being met by the staff numbers provided. Residents are in safe hands at all times. Recruitment, training and induction processes generally are adequate. EVIDENCE: Staffing on the day of the inspection was a concern. The deputy and one carer were not at work two other staff members were on holiday. The home was staffed by a senior and carer on the dementia unit and a senior from nights, an agency who had never been to the home before and a fairly new staff member on the residential unit. The manager was also on site. Staffing levels are not adequate with two staff on the dementia unit for twelve residents and three for twenty-two older people on the residential side. The impact of insufficient staff has been described earlier in the report; residents having to wait for their breakfast, no staff in the dining room at breakfast time, staff rushed throughout the day- not having time to attend to needs such as hair grooming and nail cleaning. From speaking to staff it was clear that they feel that staffing levels are not always sufficient. Comments received included; “ short staffed” and “staffing not always enough”. Of the four completed resident questionnaires received two confirmed that staff are always available when needed, two said usually. A comment was received as follows; “ When staff are short we have to wait much longer for our needs to be met”. Ashbourne Residential Home DS0000024969.V302388.R01.S.doc Version 5.2 Page 19 Positive comments were received in general about the staff which included; “ The staff are lovely”. “ The staff are wonderful”. “The staff are great”. Staff observed during the inspection were very busy and rushed however, they remained friendly and polite. It is positive that 55 of the care staff have achieved N.V.Q level 2 or above in care. Generally staff files seen were well organised and separated into different sections for easy retrieval of information. Recruitment processes were seen to be adequate with the exception of references for staff from overseas in that they were not addressed to a named person and were dated 2005 although they had not left their country until 2006. It is positive that all staff however long they have worked at the home have been encouraged to work through the organisations induction materials. It was difficult to determine if the induction materials meet the Skills for Care induction and foundation standards. Staff training is very much on target. A training matrix is available which is colour coded to alert the manager to training that is due to expire. Where there are gaps training mostly either has been or is in the process of being arranged. Ashbourne Residential Home DS0000024969.V302388.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38. The overall outcome for this group of standards is judged to be good. The manager has been approved by the Commission as a fit person to run the home. Quality assurance systems need further development. Residents’ financial interests are safeguarded. Staff receive regular supervision. Generally health and safety processes are adequate. Improvements are needed concerning the kitchen. EVIDENCE: The manager has been in post for a number of years and has been approved by the Commission as a fit person to be in charge. It is positive that since the last inspection the manager has commenced on training to achieve her Registered Managers award. The organisation has its own quality assurance system in place. The manager carries out regular audits of systems in the home. The regional manager has submitted some Regulation 26 reports as required. Ashbourne Residential Home DS0000024969.V302388.R01.S.doc Version 5.2 Page 21 It is pleasing that questionnaires have been issued to staff, residents, relatives and community stakeholders. These have yet to be analysed and published. A business plan for the year 2006/2007 has yet to be produced. Money held in safe keeping for the four residents who were case tracked was counted against balances and records and was found to be correct. Records for this money is held on computer with paper receipts for any transactions held on site. It is positive that there was two records of supervision that have been carried out within the last four months for all staff whose files were viewed. Further, a supervision matrix is available to remind the manager when supervisions are due. Health and safety , risk assessments and servicing of equipment and fire safety appliances were all satisfactory. One concern raised was the use of a wedge to prop the kitchen door open which does not comply with fire safety and could present as a fire risk. Concerns were identified in the kitchen. Dry food was stored in open packets rather than airtight containers. Date labelling was lacking on items where the original packaging had been removed. The date of retesting had passed for the probe collaboration and raw bacon was stored on the same shelf as cheese and cooked meat. All of these concerns could pose a risk of food contamination. Ashbourne Residential Home DS0000024969.V302388.R01.S.doc Version 5.2 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. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 1 9 1 10 3 11 x 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 2 2 1 1 x x x 2 1 STAFFING Standard No Score 27 1 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 3 x 2 Ashbourne Residential Home DS0000024969.V302388.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 12(1)(a) 13(4)(c) Requirement The registered persons must expand diabetic care plans to ensure that they clearly explain to staff signs and symptoms of hypo and hyperglycaemia and what to do if either of these occur. Timescale for action 24/08/06 2 OP8 12(1)(a) The registered manager must 24/08/06 ensure that all care delivery records are maintained at all times. This to include daily food / fluid intake records in respect of each resident. ( Timescales of 21/04/05 and 21/10/05 not fully met). Ashbourne Residential Home DS0000024969.V302388.R01.S.doc Version 5.2 Page 24 3 OP8 12(1)(a) 13(4)( c) The registered persons must ensure that weight recordings are accurate. 24/08/06 4 OP8 12(1)(a) 13(4)(c) 5 OP8 12(1)(a) The registered persons must ensure that where residents are assessed as being at risk (Particularly high risk) concerning tissue viability, falls, nutrition etc that this is always highlighted in the care plans. The registered provider must ensure that the personal care records (for example oral care), are maintained and up to date at all times. (Timescales of 05.02.05, 21/04/05 and 11/10/05 not fully met.) 24/08/06 24/08/06 This to include baths, showers and oral care. 6 OP8 12(1)(a) (b) 12(4)(a) (b) The registered persons must ensure that all residents are appropriately groomed and that nail care is frequent. The registered persons must ensure that all residents’ are asked their preferences concerning opposite gender staff providing their personal care. The outcome of this must be recorded on each resident’s personal file and honoured wherever possible. 24/08/06 7 OP10 20/08/06 Ashbourne Residential Home DS0000024969.V302388.R01.S.doc Version 5.2 Page 25 8 OP9 13(2) The registered persons must ensure that the doctor is asked to confirm; If resident (LR) requires vitamin B12 injections. If resident (BA) requires Ferrus Sulphate. If so arrangements must be made for these to be given. 18/08/06 9 OP9 13(2) The registered manager must continue with plans to ensure that all staff responsible for medications receive accredited medication training to ensure that all staff receive this training by the timescale applied. The homes’ pharmacy provider can be asked to provide training. 24/08/06 10 OP9 13(2) The registered person and manager must ensure that sufficient medication is available at all times to ensure that residents’ are given their medications as prescribed. (Timescale of 11/10/06 not fully met). This process must include the efficient signing in of all medications to ensure enough for the month. 28/07/06 11 OP9 13(2) The registered person and manager must ensure that an example staff signature/ initial list is produce in respect of all staff who have a responsibility for medications/ medication administration. (Timescale of 01/11/05 not 18/08/06 Ashbourne Residential Home DS0000024969.V302388.R01.S.doc Version 5.2 Page 26 met for the dementia unit. Signatures not initials on residential unit). 12 OP9 13(2) The registered persons must ensure that all medications are signed for at the point of administration. This to include the controlled drugs register. The registered persons must ask the doctor to review any medications where residents’ are continually refusing to take one example being; paracetomol. The registered persons must ensure that a copy of Southern Cross medication policy is available on both units. The registered persons must ensure that a formal process for the handing over of medication keys between shifts is implemented and maintained. The registered persons must ensure that daily routines are based on residents needs and wishes, for example rising times. The registered person and manager must ensure; That staff are available to give assistance to those residents’ who require help at every mealtime. (Timescale of 18/10/05 not fully met). 18/08/06 13 OP9 13(2) 21/08/06 14 OP9 13(2) 18/08/06 15 OP9 13(2) 18/08/06 16 OP12 12(2) 18/08/06 17 OP15 12(3) 18/08/06 18 OP15 16(2)(i) 19 OP15 The registered persons must ensure that where residents’ refuse to eat their meal alternatives are offered and food intake is encouraged. 17(2)Sche The registered person and dule 4(13) manager must ensure that; That food consumption charts 18/08/06 18/08/06 Ashbourne Residential Home DS0000024969.V302388.R01.S.doc Version 5.2 Page 27 reflect four meals offered per day. (Timescale of 08/11/05 not fully met). 20 OP15 12(4)(b) The registered persons must ensure that menus are produced in a pictorial format especially for the dementia unit. The registered person and manager must ensure that all staff are familiar with their new organisations policies and procedures in respect of adult protection. All staff must read, sign and date the said policies and procedures. This to include Dudley MBC Multi-agency policies and procedures. (Timescale of 01/11/05 not fully met- but good progress is being made). 22 OP19 23(2)(b) ( c)(d) The registered provider must inform the lead inspector based at the CSCI office of its intentions regarding the finishing of the redecoration programme. (Timescales of 20/05/05 and 20/11/05 not fully met). This to include the following; Bedrooms (That have not yet been redecorated) Toilets and bathrooms (including the staff toilet). 23 OP19 23(2)(b) The registered persons must replace window frames throughout staring with windows DS0000024969.V302388.R01.S.doc 01/09/06 21 OP18 13(6) 01/09/06 01/09/06 01/01/07 Ashbourne Residential Home Version 5.2 Page 28 24 OP20 13(4)( c) 23(2)(b) 23(2)(b) 25 OP20 26 OP21 23(2)(j) 27 OP26 23(2)(d) where pane have failing seals. This process should be fully completed by requirement date. The registered persons must ensure that the garden in the dementia unit is made safe and is usable. The registered persons must ensure that the gardens are tidied and maintained on a regular basis. The registered persons must ensure that there are at least three toilets provided on the ground floor for residential use and a visitors/staff toilet. This work must be fully completed by set date. The registered person and manager must ensure that the inset lights in the dining room are cleaned regularly. The registered person and manager must ensure that; The laundry floor is repaired. An additional sink is provided in the laundry. Adequate shelving and cupboard space is provided in the laundry. Redecoration of the laundry is carried out- to include the replacement of broken/missing tiles. That adequate regular cleaning of the laundry is undertaken. 01/09/06 24/08/06 24/09/06 01/09/06 28 OP26 23(2)(b)2 3(2)(d) 01/09/06 29 OP26 13(3) The registered persons must ensure that there are adequate disposable aprons and gloves in all high risk areas at all times ( toilets, bathrooms, laundry etc). DS0000024969.V302388.R01.S.doc 18/08/06 Ashbourne Residential Home Version 5.2 Page 29 30 OP26 13(3) The registered persons must ensure that no; Communal items are used in bathrooms and toilets (shampoo, talc etc) that items are used for individual use only and returned to bedrooms after use. Bar soap is available in bathrooms and toilets. 18/08/06 31 OP26 13(3) 32 OP26 16(2)(k) The registered persons must ensure that the dining room chairs are cleaned thoroughly on a daily basis. The registered manager must ensure that the odour n the bedroom identified during the inspection is managed and eradicated. The registered persons must ensure that there is more effective mop and bucket control within the home the following must be adhered to; Mop and buckets must all be labelled. Mop heads must be cleaned using disinfectant cycles daily and left to dry when not in use. Mop heads must be changed regularly. Records must be maintained to evidence the above. The registered person and manager must increase staff during the early morning by one. (Timescale of 01/11/05 not 24/08/06 24/08/06 33 OP26 13(3) 24/08/06 34 OP27 18(1)(a) 18/08/06 Ashbourne Residential Home DS0000024969.V302388.R01.S.doc Version 5.2 Page 30 met). This to include both units. 35 OP29 19(2) The registered persons must ensure that references for overseas staff are valid ( for example year 2006 not 2005) and are sent to a named person not ‘To whom it may concern’. The registered person and manager must produce a business plan pertaining to the financial years 2006/2007. The registered provider and manager must ensure that the homes induction and foundation programmes met requirements as per Skills for Care standards. The registered persons must ensure that wedges are not used to prop any door open (this includes the kitchen). If doors need to be held open then openers approved by West Midlands Fire service must be purchased and installed. The registered persons must ensure that; The wooden trays in the kitchen are replaced. That the probe is professionally collaborated or replaced. That where kitchen floor tiles have gaps that they are repaired. All open packets are stored in air tight containers. All foods taken out of their original containers are date Ashbourne Residential Home DS0000024969.V302388.R01.S.doc Version 5.2 Page 31 24/08/06 36 OP33 24 01/10/06 37 OP30 18(1)(a) 01/09/06 38 OP38 23(4) 18/08/06 39 OP38 13(3) 16(2)(j) 24/08/06 labelled with original use by dates. A thermometer is purchased to record the temperatures of the dry stores. The dry food store room has a good clean and tidy and that stock control measures are reestablished. Raw bacon is not stored on the same shelf as cooked meats and cheese. Sauces are all date labelled when opened and stored in the fridge. 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 Refer to Standard OP15 OP19 Good Practice Recommendations The registered persons should obtain from the CSCI website their guidance on meal provision titled ‘Highlight of the Day’. The registered persons should consider providing a kitchenette area for residents’ to use under supervision on the dementia unit. Ashbourne Residential Home DS0000024969.V302388.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands 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. 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