Inspection on 24/10/05 for Ashdale Care Home

This inspection was carried out on 24th October 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ashdale Care Home 17/01/07

Ashdale Care Home 03/01/06

Ashdale Care Home 03/03/05

Ashdale Care Home 24/09/04

Ashdale Care Home 01/03/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Ashdale Care Home 42 The Park off Park Avenue Mansfield Nottinghamshire NG18 2AT Lead Inspector Jayne Hilton Unannounced Inspection 24th October 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ashdale Care Home DS0000024623.V253764.R01.S.doc Version 5.0 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. Ashdale Care Home DS0000024623.V253764.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ashdale Care Home Address 42 The Park off Park Avenue Mansfield Nottinghamshire NG18 2AT 01623 631838 NO FAX 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) Mr A J Verjee Mrs S A Verjee Mrs Jean Dawson Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Ashdale Care Home DS0000024623.V253764.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The number of persons for whom accommodation is provided at any one time shall not exceed 26 The category of persons to be accommodated shall be the care of the elderly with General Health needs with 15 of the beds dual registered to be used for either nursing or residential Room 26 previously identified on Certificate 270 must continue to be occupied by a fully ambulant, orientated and visual acuity resident. 3rd March 2005 Date of last inspection Brief Description of the Service: Ashdale is a two-storey, privately run, 26-bedded care home providing nursing and residential care for people of both sexes over the age of 65 years. The home is a converted residential property that has been extended in keeping with the surrounding properties, providing 18 single bedrooms and 4 double bedrooms. It is situated in a quiet, residential cul-de-sac, away from the main road leading into the town centre of Mansfield, less than one mile away. This is the nearest area for shops, pubs, leisure facilities and entertainment. Access to the first floor is by a passenger lift and staircase. There are an adequate number of bathrooms, one with assisted facilities, and communal toilets for the number of residents. At the rear of the property is a small conservatory. At the front and rear of the property there are quiet, pleasant gardens. There is a car park for visitors. Ashdale Care Home DS0000024623.V253764.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on 24th October 2005 at 9.30am and was completed at 2.pm The registered manager was on leave and the nurse in charge of the shift assisted the inspector with facilitation of the assessment wherever she was able. The methodology used included the examination of three service users care plans and associated documentation. Medication management, meal provision and health and safety practices were assessed and a tour of the building took place and a sample of records was inspected. One service user was interviewed and three relatives and two staff were spoken with. The registered providers visited the home during the inspection and participated in the feedback. The inspector clarified some information with the registered manager on 31st October 2005, which resulted in an immediate requirement being issued in relation to recruitment practices. The fax number is 01623 631838 and this will be entered onto the inspection template information for the next inspection. What the service does well: Service users have their needs assessed prior to moving into the home and have their needs reviewed. Service users and relatives feel that their needs are met. Service users health, personal and social care needs are generally set out in the care plan and service users health care needs are met and their privacy and dignity respected. Service users are able to maintain contact with family/friends/representatives and the local community as they wish and generally are helped to exercise choice and control over their lives. Service users and relatives expressed satisfaction in the quality and quantity of meals and service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users live in a generally safe, comfortable, clean and well maintained environment, with safe access to indoor and outdoor communal facilities with adequate lavatories and washing facilities. The home has the specialist equipment they require to maximise their independence and rooms suit individual needs with service users possessions around them. Service user’s needs are being met by the numbers and skill mix of staff and staff, are generally trained and competent to do their jobs but not all of the mandatory training is currently being provided. Ashdale Care Home DS0000024623.V253764.R01.S.doc Version 5.0 Page 6 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 responsibilities fully and by which service users benefit from the ethos, leadership and management approach to the home. Service users are safeguarded by the accounting and financial procedures. The home was clean and free from malodour. Overall the outcomes for service user’s is assessed as positive and the home found to be well organised. What has improved since the last inspection? What they could do better: The homes recruitment policy and practices are not currently satisfactory and immediate action must be taken to rectify this. An immediate requirement is set for this. Service users do not quite have the full information they need to make an informed choice about where they live, a requirements are set in relation to the statement of purpose and service users guide. Service users would benefit from some addition to the assessment topics and the evaluation process of reviews. There are some minor areas to address to improve the documentation and records pertaining to service users care and holistic daily records should be kept for everyone. The medicines management system needs to be improved to ensure administration meets with requirements of the Medicines Act. Improvement in the meal options provision and records of nutritional intake would benefit service users further. Staff should undertake training in adult protection to ensure service users are fully protected from abuse. Attention is needed to ensure that staff, are provided with the appropriate protective clothing and that water temperatures are regulated to a safe temperature of 43 degrees and that minor repairs are carried out as listed in the report. There are some areas for improvement in relation to health, safety and welfare of service users, record keeping and quality monitoring. Ashdale Care Home DS0000024623.V253764.R01.S.doc Version 5.0 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. Ashdale Care Home DS0000024623.V253764.R01.S.doc Version 5.0 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 Ashdale Care Home DS0000024623.V253764.R01.S.doc Version 5.0 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): 1, 3, 4, Service users do not quite have the full information they need to make an informed choice about where they live, but they do have their needs assessed prior to moving into the home and have their needs reviewed. Service users and relatives feel that their needs are met. Service users would benefit from some addition to the assessment topics and the evaluation process of reviews. EVIDENCE: The Statement of Purpose was fully assessed and there are amendments required for this to fully meet with the requirements of schedule 1. The document does not state the range of needs that the care home is intended to meet in relation to the registration categories. The section for admission needs to be further developed to include information explaining whether the home takes emergency admissions and about the assessment and admission procedures. There is a statement about consultation with service users about the operation of the home, but there was no evidence in the care plans other than authorisation for the use of bedrails that there had been any consultation. Ashdale Care Home DS0000024623.V253764.R01.S.doc Version 5.0 Page 10 There was no specific information regarding the arrangements for dealing with reviews of the service user’s plan referred to in regulation 15[1], however the philosophy of care statement does include that the home involves service users, families and significant others in the assessment and evaluation of care and services. The registered person needs to explain how this is to be achieved. The number and size of rooms is not covered fully. The document identifies single and double rooms but does not specify room number and the actual measured size. There was no evidence of a service user guide in service users rooms. The inspector ascertained that the statement of purpose was combined with the service users guide. If this is the case then information is needed regarding how to access a copy of the last inspection report. Each of the care plans examined contained a full pre-admission assessment completed by the manager or a nurse qualified staff plus the Community Care Assessment (CCAs) from the social worker. The assessment tool used is a nursing based, however it is advisable to expand on the subject headings to ensure all of the needs of service users are included in assessment as specified in standard 3.3, such as foot care etc. Most of the care plans examined stated the service users wishes for the end of life, and there is a section for religious, cultural and spiritual needs. There was no indication within the documentation that service users had been risk assessed for bedroom door keys and it is recommended that this be included alongside a signature from the service user or relative that they have been issued with a copy of the service user guide. A service user spoken with and two relatives confirmed that the staff team were attentive and confirmed that their needs were met and that staff treated service users with kindness and respectfully. Specialist healthcare professionals are, seen to be, accessed as necessary, including continence advisors, community psychiatric nurses, diabetes nurses and day-to-day support from the involved GPs and the district nurse service. is obtained and used as needed by individual residents, as seen in airflow mattresses used for a residents with tissue viability concerns. Documentation is in place for recording healthcare professionals’ visits. The home has electric hoists to assist in moving and handling. Equipment for assisting safe moving and handling and specialist equipment for pressure sore prevention is available both via the home loans service and within the home. There are assisted bathing facilities and adapted toilets, with handrails and grab rails fixed throughout the home. The inspector was confused with documentation regarding the assessed needs of one service user in relation the registration category of the home, however it was ascertained that the service users primary need was nursing and that Ashdale Care Home DS0000024623.V253764.R01.S.doc Version 5.0 Page 11 the service user was appropriately placed. The inspector advises that the assessment documentation clearly indicates the service users primary need for being admitted to the home. Ashdale Care Home DS0000024623.V253764.R01.S.doc Version 5.0 Page 12 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 Service users health, personal and social care needs are generally set out in the care plan and service users health care needs are met and their privacy and dignity respected. There are some minor areas to address to improve the documentation and records pertaining to service users care and holistic daily records should be kept for everyone. The medicines management system needs to be improved to ensure administration meets with requirements of the Medicines Act. EVIDENCE: The care plans examined were well documented, comprehensive, easy to read and describe clearly the holistic needs of the resident and how these needs are provided. Risk assessments are completed. Involvement of resident and relative was not however clearly evident in the care plans examined however a service user and relative confirmed that the manager had discussed care plans with them, but they had not signed in agreement. Care plans are reviewed monthly, each care plan being reviewed on the back of the care plan page plus a review of risk assessments. The review date only Ashdale Care Home DS0000024623.V253764.R01.S.doc Version 5.0 Page 13 was seen on the care plans and therefore no evidence was seen of appropriate evaluation and sometimes no indication who had carried out the review. Daily communication is only completed where there is anything significant to document. The inspector advised that it is good practice to ensure the holistic needs of service users are documented at least once daily to provide evidence of staff attention/input and observations. It is also recommended that the approach be more holistic than problem focused. Assessments were in place for tissue viability, mobility, infection control and nutrition. An assessment score was missing on the initial nutritional tool of one-service users who had weight loss noted, swallowing difficulties and other medical problems. Appropriate action was seen to have been taken in managing the service users issues however care should be taken to ensure that documentation is completed appropriately. Two members of staff had signed to witness a conversation regarding a decision made by the service users after being given advice. The service users signature should also be obtained in these circumstances. Authorisation for bedrails were seen and signed by the service users or relative, however these need to be reviewed periodically. One service users bedrail authorisation had been completed in 2002 by a relative now deceased. There was no running record of history of falls and this is recommended and which can be used to evaluate events of falls and what action is being taken to minimise these. Accident records were examined, one record had no detail of when the accident occurred, no date, time etc. Care plans were in place for dealing with aggression. Continence appears to be well managed and a service user reported that the GP is contacted promptly if required. Relatives of one service user reported how the staff team had improved the health and well being of their relative who had been very poorly the year previous and that they were always contacted when any change in health condition occurred. Wound care appears to be well managed and documented. A medication round was observed and it was noted that medication was signed for before being visibly being observed as taken, which is not good practice. Medication must only be signed for after the service user has taken the medication and which has been visibly seen as taken. Medication administration records were overall satisfactory, however on sheet had a missing signature and no indication of why the medication had not been administered on this day. It became apparent that the service user had a hospital appointment this day. Ashdale Care Home DS0000024623.V253764.R01.S.doc Version 5.0 Page 14 Each Medication administration records (MAR) sheet in fronted by a photograph of the resident. As required (PRN) drugs are recorded appropriately and clearly. Only nurse-trained staff administer medications but some care staff attended drug administration training as well as the nurse-trained staff and the manager. The names, signatures and initials of all staff who administer medications are recorded at the front of the MAR sheets file. The treatment room was not inspected at this visit. Service users and relatives spoken with confirmed that privacy and dignity was respected at all times including regarding receipt of mail and in relation to visitors. Staff were observed to treat service users, with respect and appropriate communication and interaction witnessed. Curtains are in place for residents in shared rooms to provide privacy. Ashdale Care Home DS0000024623.V253764.R01.S.doc Version 5.0 Page 15 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): 13, 14, 15 Service users are able to maintain contact with family/friends/representatives and the local community as they wish and generally are helped to exercise choice and control over their lives. Improvement in the meal options provision and records of nutritional intake would benefit service users further. Service users and relatives expressed satisfaction in the quality and quantity of meals. EVIDENCE: As there was not much evidence regarding activities provision available at this visit, the inspector will explore this standard in detail at the next visit. One service user explained that she was the only service user who could actively participate in activities, but stated that a piano player attends the home to entertain service users. Relatives reported that they were always made welcome and there was evidence that relatives are provided with a drink and can stay for a meal should they choose to. Ashdale Care Home DS0000024623.V253764.R01.S.doc Version 5.0 Page 16 Residents who wish to bring their personal belongings with them may do so, as seen in the rooms of residents case-tracked. Residents and their relatives say they are consulted on their wishes and preferences. The details of advocacy agencies are displayed for any resident who wishes to contact them. A service user confirmed that her independence and autonomy was respected and that she could choose when to go to bed and when to get up etc. The service users were enjoying breakfast on the arrival of the inspector and those service users who required assistance were attended to in an appropriate manner. The mealtimes appeared well organised to ensure those that needed assistance had the attention they needed. The lunchtime menu was sausage, mashed potatoes, green beans and cabbage. Those service users who did not like sausage were served pork. Although there was evidence that those who can advocate their dislikes were served alternatives and this was supported by a service user reporting that the cook had provided her with jam sandwiches one day when requested there is no second choice provided on the actual menu, neither was there any evidence that service users are actively given two options to choose from. It was recommended that two options be provided on the menu itself and for staff to inform the service users what is available and to record the choice and keep as documentary evidence. Regulation 17, schedule 4 [13] states that “records must be kept of the food provided for service users in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory, in relation to nutrition and otherwise, and of any special diets prepared for individual service user”. The inspector recommends a simple and practical way of achieving this along side a planned written menu with at least two options is to supply a page a day diary and to list the meal options chosen and taken by each service user, with the probed temperature record with the food item listed. This provides an instant daily record, which can be evaluated easily. Fridge and freezer temperatures can be recorded on the page also, which reduces several pieces of paperwork. Standard 15 was assessed as exceeded at the previous inspection, unfortunately there was not enough evidence at this inspection to assess this standard other than met Ashdale Care Home DS0000024623.V253764.R01.S.doc Version 5.0 Page 17 Relatives spoken with state that the residents enjoy their meals and a relative who ate a meal on the day supported this. The lunch meal provided on the day of the inspection appeared tasty and appetising and was said by all residents observed to be delicious, as seen by all the clear plates returned to the kitchen. Drinks are supplied and encouraged throughout the day as seen on every resident’s tables beside their chairs in the lounge. Fluid balance charts show that drinks are also given during the night. Ashdale Care Home DS0000024623.V253764.R01.S.doc Version 5.0 Page 18 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 Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Staff should undertake training in adult protection to ensure service users are fully protected from abuse. EVIDENCE: Two relatives spoken with were not sure about how to make a complaint should they have one, despite the complaints procedure being displayed in the main entrance close to the visitor’s book. It is therefore recommended that relatives are reminded of this process or be issued with a copy of the service user guide. A service user confirmed that she felt able to make a complaint easily and that it would be dealt with appropriately. The inspector was not able to inspect the complaints records, as these could not be located in the manager’s absence. There was a copy of the Nottinghamshire Committee for the Protection of Vulnerable Adults Guidance observed in the home and staff, spoken with, were clear that they would report any concerns. Staff have not undertaken training in adult protection apart from the brief coverage in their NVQ training. It is recommended that this be arranged. Ashdale Care Home DS0000024623.V253764.R01.S.doc Version 5.0 Page 19 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): 19-30 Service users live in a generally safe, comfortable, clean and well maintained environment, with safe access to indoor and outdoor communal facilities with adequate lavatories and washing facilities. The home has the specialist equipment they require to maximise their independence and rooms suit individual needs with service users possessions around them. Attention is needed to ensure that staff are provided with the appropriate protective clothing and that water temperatures are regulated to a safe temperature of 43 degrees and that minor repairs are carried out as listed in the report. EVIDENCE: Ashdale Care Home DS0000024623.V253764.R01.S.doc Version 5.0 Page 20 The lounge and dining facilities appeared comfortable, safe and well maintained and ramps provide access to the garden areas. A patio door gives access to the front of the home for relatives and staff to take residents out in wheelchairs as the original front door has steps up to it. There are some loose paving slabs on the entrance to the laundry area. A door leading to the staff changing area and laundry was not closing properly, due to a loose carpet strip. Residents who need wheelchairs have sufficient space in their rooms to facilitate them. A call system is provided in every bedroom and communal areas. The communal baths and toilets inspected are well decorated and maintained and the flooring in a good state of repair. They are sufficient in number and adequately equipped to meet the needs of the residents. The toilet and bathroom facilities were not clearly identifiable and it is recommended that appropriate signs and picture symbols be fixed for this purpose. Specialist equipment has been seen at the home. Involvement of healthcare professionals is accessed as necessary. A passenger lift gives access to all areas of the upper floor. Ramps provide access to the garden areas. A patio door gives access to the front of the home for relatives and staff to take residents out in wheelchairs as the original front door has steps up to it. Residents who need wheelchairs have sufficient space in their rooms to facilitate them. A call system is provided in every bedroom and communal areas. Bedrooms examined on the day of the inspection were personalised, appropriately equipped and clean. One service user’s room needs the decorative boarder replacing. A sample temperature was taken from the communal and bedroom water outlets. Most were satisfactory however one basin in a ground floor toilet tested at 61 degrees which may pose a risk to service users. There was no ‘hot water’ notice on this particular outlet either. A light was not working in a ground floor bathroom. Lighting is of a domestic style and radiators are guarded or of the low surface type. Sluice facilities are provided and the laundry room equipped with two washers with sluicing and disinfecting programmes and one drier. There were no gloves available in the laundry room, staff reported that these were kept locked away. The home was clean and free from mal-odour. Ashdale Care Home DS0000024623.V253764.R01.S.doc Version 5.0 Page 21 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, 29, 30 The numbers and skill mix of staff is meeting Service user’s needs. The homes recruitment policy and practices are not currently satisfactory and immediate action must be taken to rectify this. Staff, are generally trained and competent to do their jobs but not all of the mandatory training is currently being provided. EVIDENCE: The staffing rota was examined and found to be satisfactory and both staff a service user and relatives confirmed 4 staff and one nurse were provided each daytime shift and two care staff and a nurse at night. Domestic, catering and laundry and maintenance staff, support the care staff. The inspector could not access the personal files of staff as the manager was on leave. On speaking with a new member of staff it transpired that she had not had a Criminal Records disclosure returned prior to employment and was not aware of any other checks such as POVA First being carried out. The inspector spoke with the providers who stated that the manager would have this in hand but they asked for confirmation about the process for POVA checks, as they were unsure. On speaking with the registered manager on 31st October 2005, it was explained that the Registered Provider has been advised to de-register as an umbrella body by the CRB and therefore three staff had been employed without the appropriate checks being carried out. One had now left. The Ashdale Care Home DS0000024623.V253764.R01.S.doc Version 5.0 Page 22 registered manager reported that two satisfactory references had been obtained and that the staff, were being supervised. Therefore an immediate requirement has now been issued to ensure staff are not employed without the appropriate recruitment checks and to obtain the necessary POVA clearance of the remaining staff within 14 days. Staff training records, were not examined, but staff were able to confirm training and induction for manual handling but two carers spoken with had no training in food hygiene despite being food handlers. One carer reported training undertaken in fire safety, infection control and Dementia training. The registered manager should provide an annual training plan which is available for inspection and which must include mandatory training for all staff in the following, first aid, infection control, health and safety, fire safety, manual handling and food hygiene certificates. Ashdale Care Home DS0000024623.V253764.R01.S.doc Version 5.0 Page 23 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, 32, 33, 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 responsibilities fully and by which service users benefit from the ethos, leadership and management approach to the home. Formal supervision needs to be evidenced. Service users are safeguarded by the accounting and financial procedures. There are some areas for improvement in relation to health, safety and welfare of service users, record keeping and quality monitoring. EVIDENCE: Service users, relatives, staff and the registered providers praised the registered manager for her commitment to the service users and organisation of managerial responsibilities. Comments were that the manager/matron is approachable. The manager is a first level nurse and NVQ assessor, has a D33 (Internal Verifier for NVQ) certificate, has received intensive training in palliative care Ashdale Care Home DS0000024623.V253764.R01.S.doc Version 5.0 Page 24 and business management and has attended courses on wound care and continence assessment and management. The previous inspection found that the standard regarding the management of the home exceeded the standard, however as the manager was not in attendance and there are requirements set at this visit the standard is assessed as met only. There was no evidence of quality monitoring available on this visit. Service users and relatives were not aware of any service user surveys being carried out. A sample of service users small cash held records were examined and found to be satisfactory. As the manager was not available staff personal files could not be accessed, however care staff spoken with reported that formal supervisions [1:1 time] with the manager are not taking place. Care plans were observed to be left accessible in the office with door wedged open. The inspector held a discussion with the registered provider and nurse in charge in relation to the security of personal information of service users, which could easily have been accessed by visitors. Service users personal information must be stored securely and under the requirements of the Data Protection Act 1998. The fire safety test records were examined and found to be inaccurate in terms of dates and overdue by two weeks. Emergency lighting tests were being carried out 6 monthly and it is recommended that these be checked monthly. Minor omissions and errors were found within the care plans, accident records, and Mar sheets also. The health and safety practices overall appeared to be fairly satisfactory. The records for maintenance of equipment and servicing contracts were satisfactory including gas and electrical safety checks. There was however no evidence of a fire safety risks assessment and a several doors were noted to be wedged open. There was a bucket with cleaning materials left unattended for most of the inspection, which was close to service users bedrooms and access to the toilet and bathroom areas. The Health and Safety poster was completed. Ashdale Care Home DS0000024623.V253764.R01.S.doc Version 5.0 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 3 3 3 3 2 2 STAFFING Standard No Score 27 3 28 X 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 1 X 3 1 2 2 Ashdale Care Home DS0000024623.V253764.R01.S.doc Version 5.0 Page 26 Are there any outstanding requirements from the last inspection? N/A 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 Requirement Timescale for action 24/12/05 2 3 OP1 OP9 4 OP9 5 6 7 8 OP14 OP19 OP25 OP26 Ensure the Statement of Purpose and Service user guide meets with the requirements of Schedule 1 regulation 4 and 5 as specified in the main body of the report 5 Provide evidence that all existing service users have been issued with a service users guide 12, 13, Ensure the medication 16,17 administration records are not signed before the service user has been visually observed as taken. 12, 13, Ensure the reason why 16,17 medication has not been administered is documented on the medication record 24 Ensure evidence is provided that service users are consulted in relation to meal options. 23 Secure the loose carpet strip and ensure the door fits flush to the laundry area. 12, 13,1 Ensure the hot water is regulated 6, 23 to a safe temperature in communal water outlets 12, 13, 16 Ensure staff have personal protective clothing available at DS0000024623.V253764.R01.S.doc 24/12/05 24/12/05 24/12/05 24/12/05 24/12/05 24/12/05 24/12/05 Ashdale Care Home Version 5.0 Page 27 9 OP29 10 OP29 11 12 13 14 OP30 OP33 OP36 OP37 15 16 OP38 OP38 all times The registered provider must take appropriate action to ensure that staff are not employed until the required recruitment checks have been carried out satisfactorily 19 The registered provider must ensure that the staff employed without the appropriate checks have a POVA first register check by 14th November 2005, and are supervised; failure to comply with this will result in the staff needing to be removed from duty. 18 Ensure all food handlers undertake food hygiene training [including care staff] 24 Ensure systems are in place to consult with service users about the care and services provided 18 Provide evidence of formal supervision 17 Ensure all records are up to date, including fire safety check records, and that service users personal information is kept secure 12,13, To submit a Fire risk assessment 16,17,23 for the home. [Fire Precautions [Workplace] Regulations.] 12,13, 16, Ensure cleaning materials are 23 stored securely as required by regulation [COSHH] Control of substances Hazardous to Health. 19 24/10/05 14/11/05 24/01/06 24/12/05 24/12/05 24/12/05 24/12/05 24/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ashdale Care Home DS0000024623.V253764.R01.S.doc Version 5.0 Page 28 1 OP3 2 3 OP4 OP7 Expand the assessment document to include the topics listed in Standard 3.3 and include evidence that service users have the opportunity to hold a door key unless a risk assessment states otherwise. Ensure the service users primary need for admission is clearly stated in the assessment documentation Provide written evidence that service users are in agreement to their care plan and observations are recorded in a holistic style on a daily basis. Include a history of falls record in the service users care plan and use the information to evaluate the events and prevent further occurrence. Use a page a day diary to keep a record of food provided, options taken and other kitchen records. Provide training for staff for adult protection. Provide appropriate signs and picture symbols for service users to identify toilet and bathrooms etc. Replace light bulbs promptly Replace the damage decorative boarder in the identified bedroom. Provide evidence of an annual training plan and ensure this is available for inspection. Emergency lighting should be tested monthly 4 5 6 7 8 9 10 11 OP8 OP15 OP18 OP19 OP19 OP24 OP30 OP37 Ashdale Care Home DS0000024623.V253764.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Ashdale Care Home DS0000024623.V253764.R01.S.doc Version 5.0 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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