Inspection on 27/06/07 for Ashcroft House

This inspection was carried out on 27th June 2007.

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

Ashcroft House 01/02/10

Ashcroft House 17/11/09

Ashcroft House 23/06/09

Ashcroft House 25/06/08

Ashcroft House 12/06/06

Ashcroft House 23/01/06

Ashcroft House 11/10/05

Ashcroft House 02/08/04

Ashcroft House 14/04/04

Ashcroft House 11/02/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Ashcroft House Fairview Close Wilderness Hill Cliftonville CT9 2QE Lead Inspector Clair Brown Unannounced Inspection 10:58 27th June 2007 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 Ashcroft House DS0000040622.V339275.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. Ashcroft House DS0000040622.V339275.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashcroft House Address Fairview Close Wilderness Hill Cliftonville CT9 2QE 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) 01843 296626 01843 571551 Regal Care Homes (Margate) Ltd Jacqueline Ruth Butler Care Home 88 Category(ies) of Dementia - over 65 years of age (49), Old age, registration, with number not falling within any other category (39) of places Ashcroft House DS0000040622.V339275.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th June 2006 Brief Description of the Service: Ashcroft House is an exceptionally large detached property, that was previously a hospital, with three floors, which have additional wings, currently the top floor is closed whilst the company considers refurbishment requirements. The Home offers a mixture of care provisions; residential, nursing and dementia. The home is situated within walking distance of local amenities. There is a shaft lift to access the upper levels. The home has it’s own secure garden area. There is limited parking for cars available. There are additional costs for items such as hairdressing, chiropody, newspapers and taxis. Fees at this home range from £312.81 - £660 per week. Ashcroft House DS0000040622.V339275.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection that consisted of an unannounced visit to the home on 27th June 2007 by one inspector and lasted over 7 hours. The inspection takes account of information received from a variety of sources including written information from the registered providers and manager, service users and care managers. The previously made requirements and recommendation from other inspections were inspected and all key standards. The inspector spent time observing service users and the care staff. A partial tour of the premises was conducted. Documents and records were seen and service users files were case tracked. What the service does well: What has improved since the last inspection? Following the last inspection there were 34 requirements made, many of these have been met or there are plans being drawn up to meet them. There are a total of 15 requirements in this report. The home was recently sold. The new registered provider has started to invest in the home. There has been an increase in the quantities of new movement & handling equipment being purchased. New beds and over bed tables have been provided. A second dishwasher has been provided in the kitchen, the laundry has been refurbished with new washing machines and tumble dryers. There are now designated budgets for the garden and leisure activities. Staff have benefited from a bonus and pay rise. There has been an increase in training courses. All of this has resulted in improved staff moral. This in turn has greatly improved the atmosphere of the home. A deputy manager has been appointed, which means most mornings, there are two qualified nurses on duty. There has also been an increase in the number of night staff on duty. Ashcroft House DS0000040622.V339275.R01.S.doc Version 5.2 Page 6 The manager has successfully gone through the fit persons process and is now the registered manager of the home. This is the first time in years that the home has benefited from the stability of having a registered manager. The registered manager has been given a budget to manage the home, she is happy and feels supported by the registered provider, but also that she is enabled to actually manage Ashcroft House. What they could do better: The new registered provider has lots of plans to improve the environment and facilities within the home. These need to be formally produced as a business/improvement plan with timescales that can be monitored. The homes statement of purpose needs to be reviewed to ensure the information in it is accurate. Care plans still need to be improved to make sure that all of a persons care needs are written in the care plan and then include detailed instructions on how meet these. The registered manager needs to make sure that the home complies with MRHA (medicines and healthcare products regulatory agency) alerts, about faulty equipment and safety procedures, such as blood sugar monitoring equipment and the use of cot sides. Practices by staff, for making sure that people’s dignity is protected, must be improved. Staff must put into practice what they have been taught at training courses, such as movement & handling and they must not perform unsafe lifts. Different methods of communication, needs to be introduced (such as pictorial) to give people a greater range of choice and alternative methods of expressing their views. The home needs to write a mental capacity policy, taking into account the new laws. The registered manager needs to assess the homes and staff ability to care for those who are dying and consider appropriate training for the nurses and the care staff. For all staff a more in depth dementia training would be appropriate. The registered manager needs to introduce the assessment of staffs competencies once completing training. Some practices for administering of medication need to be improved, although there has been a significant improvement since the last inspection. Ashcroft House DS0000040622.V339275.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. The summary of this inspection report can be made available in other formats on request. Ashcroft House DS0000040622.V339275.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 Ashcroft House DS0000040622.V339275.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): 136 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users needs are fully assessed prior to admission to the home. The home does not provide intermediate care therefore standard 6 is not applicable. EVIDENCE: The pre-admission assessment for a prospective service user was seen, it was completed by the manager prior to admission and a copy of the KCC assessment and care plan. The manager has already made contact with specialists to support the home and the service users with some of their specific needs. Ashcroft House DS0000040622.V339275.R01.S.doc Version 5.2 Page 10 The statement of purpose includes some information regarding its registration relating to it’s ability to provide nursing care and this would depend upon the skills and training of its nursing staff. This document also includes information regarding activities; this indicates that these occur daily, however, this could be further clarified by adding the number of activity hours spent each week on each floor. There are further part time activities persons employed to work on the first floor. However, it did include the minimum information required. The manager confirmed the home does not provide intermediate care. Ashcroft House DS0000040622.V339275.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 10 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care plans have improved but do not identify all of the service users needs. Service users are supported to access health care services. The overall medication practices have improved but there are some practices that need to improve further. Service users are not always cared for in a dignified manner. EVIDENCE: Three service users files were assessed from both floors. These showed that there has been an overall improvement in the information gathered, the completion of assessments, reviews and the actual writing of the care plans. However the case tracking of the service users files, also found that further improvement is required. When the care plan is reviewed the oldest part of the care plan is first, there is no way of identifying if it is current or discontinued and the fact was that these needs were no longer valid and the service users need had changed significantly. Although this had been recorded Ashcroft House DS0000040622.V339275.R01.S.doc Version 5.2 Page 12 later on, the original needs had not been recorded as discontinued and could cause confusion. One service users had a stoma but this was not in the care plan, the carer stated the bag needed to be changed every three days, again this was not in the care plan. One service users was seen to have a dressing on their leg, the care plan contained body maps and skin integrity assessments, however these had not been updated to include the dressing on the leg. In fact there was no record of this wound in the service users file, or in the daily records. The District Nurse’s own records revealed that they had been asked to visit to treat a skin tear six days earlier. The third person case tracked had complex needs and their condition was deteriorating, resulting in possible personality & behavioural changes. The care plan failed to acknowledge that the challenging behaviours may be due to their illness, therefore the instructions on how to respond to this may not have been appropriate and implied a difficult personality. The content of the daily records varies in quality and detail. Some staff do not refer to the care plan, or provide actual details of the care provided whilst others write detailed records of the care provided and the events of the day for the service user. Observations made during the course of the inspection were varied, some service users were smartly dressed and appeared well cared for, others looked unkempt, some men were unshaven with a couple of days growth. One service user was being cared for behind screens in the lounge, screens were placed in front of the chair. Staff did not ensure that the screen were positioned to maintain the service users privacy & dignity, not only was an unsafe lift observed from the other side of the screens but also the exposure of the service users bare bottom. Some of the service users do have illnesses that could shorten their life expectancy. The training matrix shows that none of the staff have completed a care of the dying course. The registered manager needs to compare the skills of staff and services provided to the guidance on the CSCI website for providing terminal care. The home does have a policy for caring for the dying. A medication audit was conducted in the nursing section of the home. This found that the MAR charts and medication records were up to date and that administration of the medication corresponded. However, the bottle of one service users liquid medication (for epilepsy) and their medication records revealed that the liquid had not been administered. The times of administering some medication that should be taken before food was not occurring. Some service users required medication administered through plasters, the home does not have a procedure for recording the sites used. The controlled drugs Ashcroft House DS0000040622.V339275.R01.S.doc Version 5.2 Page 13 and there records corresponded and no errors were found. The inspector arrived at the home at 10.00hrs in the morning to find that the residential service users 08.00hrs medication round was still being conducted. The MRHA in 2005 issued an alert regarding blood glucose monitoring equipment, during the course of the inspection staff stated that they share the testing pens between service users. This does not comply with the MRHA guidance. Ashcroft House DS0000040622.V339275.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a small range of social activity and stimulation provided. Relatives are welcomed to the home to provide the service users with the contact they need. Meals provided offer a varied diet for the service users. The home does not use different ways of communication to promote choice and personal control. EVIDENCE: Relatives are welcome to visit the home at any reasonable time and are encouraged to bring possessions in from the service users home to personalise their bedrooms. On the ground floor there are two part-time activities persons working a total of 48 hours per week. On the first floor the activities person works 40 hours per week. The statement of purpose claims that activities are provided on a daily basis. The activities person has recently introduced “doll therapy” on the Ashcroft House DS0000040622.V339275.R01.S.doc Version 5.2 Page 15 first floor (where those with dementia are cared for). The first floor also benefits from having a designated area for arts and crafts. Time was spent talking with the cook, who explained that the food budget has been increased by 50 pence per person per day. There are two choices of main meal provided each day. The menu is only produced in a written format and even though staff ask service users what they would like to eat, this is not supported by using formats such as pictorial to assist them with making choices. The cook provides a traditional home cooked menu that includes dishes such as toad in the hole, lamb hot pot and Sunday roasts and bakes cakes for tea. Although sandwiches are provided as a supper, the three main meals are very close together; breakfast 7.30 –08.00, lunch 12.30-13.00, evening meal 16.30 –17.00hrs. There is insufficient dinning space to enable everyone to eat in the dinning room, some eat in the lounges and others eat in their bedrooms. Ashcroft House DS0000040622.V339275.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has formal policies and procedures in place to uphold adult protection, supported by staff who have attend appropriate training. The home has a complaints procedure, which is now implemented. EVIDENCE: The home has received seven complaints, five of these have upheld the issues raised by the complainants and two were partially upheld. This demonstrates that the home is being objective when investigating concerns and complaints. The records held of these complaints showed that they were fully documented and details of the investigations conducted were recorded. According to the training matrix all of the care staff have now completed adult protection and abuse training. The home has reviewed it’s complaints policy and now includes timeframes. Ashcroft House DS0000040622.V339275.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 20 22 23 24 25 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There has been little change to the actual building since the last inspection visit. There are improvements in the provision of equipment and practices. The overall cleanliness of the home is satisfactory, however some areas continue to have strong offensive odours. EVIDENCE: There has been no change to the physical environment since the last inspection visit. However, there has been an increase in the provision of equipment and aids to assist and support service users, such as individual peoples slings for the hoists, wheelchairs and other movement & handling equipment. Ashcroft House DS0000040622.V339275.R01.S.doc Version 5.2 Page 18 The registered providers have upheld purchasing contracts made by the previous owners for some new furnishings. The registered manager stated that there are plans to refurbish the entire building, with en-suite facilities for bedrooms, all new furniture and décor. There are also plans to replace the windows and doors, (currently many of the windows are in a poor state of repair). At the back of the statement of purpose is a generalised business plan relating to the refurbishment, however, a formal plan with timescales and clear details of the proposed work has not been produced. The registered manager, was not clear of exactly how the refurbishment of bedrooms would work, and assumed that people would be moved into vacant rooms for a few days at a time. There were some offensive odours around the building, however the overall cleanliness had improved. The sluice areas were seen to be clean and clinical waste bins used appropriately. Overall there was an improvement in infection control procedures. One service user was seen to be in bed with the cot-sides in use, these did not have the bumpers in place, care staff stated the service user did not like them. The home must adhere to MHRA safety guidelines, and find alternative equipment to meet the service users needs. The fact that service users do not like something does not allow homes to fail to comply with safety guidelines. The laundry has been fitted with new industrial washing machines, tumble dryers and shelving. Ashcroft House DS0000040622.V339275.R01.S.doc Version 5.2 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 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 adequate. This judgement has been made using available evidence including a visit to this service. At times staffing levels are at a minimum level to meet the service users needs, despite an increase in staffing numbers. Staff have completed a variety of training since the last inspection visit but do not put into practice what they have been taught. Recruitment procedures are thorough and ensure the welfare of the service users. EVIDENCE: At the time of the inspection visit there were 67 service users, plus one new admission that day. The duty rota show that there is 1 registered nurse, plus the deputy manager(RGN) 4-5 care staff on duty, on the ground floor (nursing/residential) during the day for 36 service users. On the first floor(dementia) 1 supervisor all day and 4-5 cares in the morning and 3 in the afternoon and evening for 31 service users. At night the staffing numbers have been increased from 5 to 6 with 3 staff on each floor. Care staff are supported by teams of ancillary staff, for cleaning, catering, laundry and maintenance, as well as an administrator. Thirteen of the 37 care staff have worked hard and have now completed their NVQ level 2 or 3 in care, further carers have been enrolled on the training. Ashcroft House DS0000040622.V339275.R01.S.doc Version 5.2 Page 20 Further in house training has been completed which has been purchased from a training company, which includes infection control & adult protection. All staff have completed a basic introduction to dementia and the registered manager has completed a 3 day course. She plans to send the senior carers on the 3 day training course. The registered manager had not compared the content of some of the specialist training against the modules produced by skills for care in subjects such as dementia, infection control and medication. Care staff do not to put into practice their training. Observations of movement and handling techniques showed that unsafe lifting techniques are being used. An under arm lift was performed in front of the inspector. This was discussed with the carer concerned who stated they had attended movement & handling training but was not initially aware of performing an unsafe lift. When staff have completed training they are not been assessed, to deem them as competent. The registered manager has implemented the new providers induction standards training, who informed her this complies with Skills for Care, common induction standards. Three recently recruited members of staff’s file were assessed and this showed that a thorough recruitment procedure had been used to employ these staff. Ashcroft House DS0000040622.V339275.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 32 33 35 36 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There has been a positive improvement in the overall management of the home. Service users monies are managed appropriately. The quality assurance processes, need to be developed further. EVIDENCE: The manager has been successful in their application to become the registered manager. The registered manager has the appropriate skills and qualification to manage the home. Ashcroft House DS0000040622.V339275.R01.S.doc Version 5.2 Page 22 There has been an improvement in the management of the home and this is most evident in the change of atmosphere and attitude of the all of the staff. When speaking with staff they are now happy and more content, they feel valued by the registered manager but also by the new owners. The investment in equipment, pay rises and that they feel listened to, has had a very positive effect on them and therefore on the whole service. The staff stated they are supported and no longer wish to leave. The atmosphere is more content within the home, with less anxiety being apparent about the inspection taking place. The style of management has changed, with the registered manager being given a budget and she stated that she feels she is now actually able to manage the home and have a degree of control. There is an acknowledgment that there are areas that require improvement but this needs to be formalised into a written business/improvement plan with timeframes and clear details. Many of the outstanding requirements have been met. The pre-inspection questionnaire completed by the registered manager states that the Home’s environmental health & safety certificates are up to date. The fire risk assessment has been reviewed and updated. The registered manager stated that the home has reverted to invoicing relatives etc, for service users spending, rather than holding cash within the home. One service user is supported to manage their own bank account. Records of service users spending were seen and no errors were identified. The registered manager stated that she now regularly conducts supervision with her staff and has regular staff meetings. Records of supervision dates and times were seen. The registered manager confirmed that they regularly survey service users and relatives, and conducts audits of medication as part of the quality assurance programme. However, this information needs to be collated into a final report for each year. However the home changed ownership recently and the new providers will be introducing their own systems for quality assurance. The new providers policies and procedures have been implemented within the home. Currently no mental capacity policy has been produced taking into account the recent changes in the law. Ashcroft House DS0000040622.V339275.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 X 2 2 2 2 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 X 3 3 X 3 Ashcroft House DS0000040622.V339275.R01.S.doc Version 5.2 Page 24 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 OP1 Regulation 4 sch 1 Requirement The information within the Statement of Purpose must be factually accurate. This is to ensure that people are kept informed about the service and can make an informed decision. Care plans must identify all of the service users needs and provide staff with clear instructions on how to meet these needs. This is to ensure that service users have all of there care needs met. Daily reports must record all aspects of care provided and be linked to the care plan. This is to evidence the care provided and to enable other staff to monitor the service users overall condition and needs and what care has been provided. Previous requirement: 31.12.04 & 31.03.06 3. OP8 12 13 The registered manager must DS0000040622.V339275.R01.S.doc Timescale for action 30/09/07 2. OP7 12 13 14 15 16 30/09/07 30/08/07 Page 25 Ashcroft House Version 5.2 comply with MRHA alerts relating to the correct equipment to use when testing service users blood glucose levels. People must have individual devices, that also protect staff from possible needle stick injury. This is to protect service users from contracting blood born diseases such as Hep B and to protect staff from possible needle stick injury. Medication must be administered at the prescribed time and in accordance with the manufacturers instructions, such as “take before food”. Staff must not take an excessive amount of time to complete the medication round, compromising the safe administration of the next medication round. Staff must ensure that prescribed medication that is not issued in blister packs is also administered, such as liquids. The registered manager must seek clarification of the service users need for the GTN spray that had been prescribed only 2 months earlier. Staff must not assume that it is no longer valid. This is to ensure that service users receive their prescribed medication at the correct times, correct dosage and the correct medication to meet their needs. 5. OP10 12 (4)(a) All staff must protect service users inappropriate exposure. This is to ensure their privacy and dignity is maintained. The registered manager must assess the home and it’s staff DS0000040622.V339275.R01.S.doc 4. OP9 12 13 16 17 23 sch 3 30/08/07 30/08/07 6. OP11 12 sch 3 30/09/07 Ashcroft House Version 5.2 Page 26 ability to meet the criteria for providing terminal care against the CSCI “end of life planning” and implement any changes identified. This is to ensure that the home and the staff have the appropriate skills, knowledge, equipment and resources to provide care for those who are at the end of their life. 7. OP14 12. (2) (3) The registered manager must use different formats for communication/documentation, such as pictorial menus, promoting individual choice. This is to ensure that service users are supported to exercise personal autonomy and choice. Previous requirement: 16/08/06 8. OP19 23 The registered provider must produce a plan with timescales for the proposed refurbishment of the building and provide the CSCI with a copy. Including details of the installation of new windows & doors, decorating of bedrooms, installation of ensuite facilities, provision of new furniture throughout the home, air conditioning in communal rooms and the building of conservatories. This is to ensure the building and the environment is maintained to a standard that meets the service users needs and is kept in good condition. 9. OP22 13 (4)(a)(c) The registered manager must use cot bumpers with cot-sides in accordance with the MRHA or provide alternative forms of DS0000040622.V339275.R01.S.doc 30/11/07 30/08/07 30/08/07 Ashcroft House Version 5.2 Page 27 approved cot-sides. This is to ensure the health & safety of service users, protecting them from possible injury or death. The premises must be kept free from offensive odours throughout. This is to ensure people living in the home experience a pleasant environment to live in. Previous requirement: 16/08/06 50 of care staff must have the NVQ Level 2 in care qualification. This is to ensure staff have the knowledge and skills to provide care. Previous requirement: 31/12/06 12. OP30 12 18 The Induction programmes must comply with the requirement of Skills for Care common induction standards. Care staff must complete a more advanced dementia training programme, in accordance with the skills for care dementia module. Once staff have completed a training session, the registered manager must make provision to assess them as competent. This is to ensure that staff have the appropriate skills and knowledge to meet the needs of caring for people. Previous requirement:30.06.06 For the Home to develop and implement an annual quality monitoring system. Producing a report, copy must be sent to the Commission. DS0000040622.V339275.R01.S.doc 10. OP26 16 30/08/07 11. OP28 18 30/11/07 30/10/07 13. OP33 24 30/12/07 Ashcroft House Version 5.2 Page 28 This is to enable the homes management to carefully monitor the quality of service it provides and identify areas that require improvement and then to act upon these. Previous requirement: 30.04.05 & 16/08/06 14. OP38 13(5) Staff must not perform unsafe movement & handling lifts, such as the underarm lift. This is to protect both the service user and the staff from injury. 30/08/07 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 OP9 OP12 Good Practice Recommendations To have a procedure, such as a body map with sites numbered, for the recording the site used on the body for administering medication through plasters. It is recommended that the number of leisure activity hours, are increased. The range of activities provided be more varied and increased, especially on the nursing/residential floor to meet the more of the service users social needs and interests. To consider the moving the meal times, to give a more even spread of meals throughout the day. The home should provide foot operated peddle bins rather than swing bins for the prevent of the spread of infection. The registered manager needs to produce and implement a mental capacity policy. 3. 4. 5. OP15 OP26 OP38 Ashcroft House DS0000040622.V339275.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 - 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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