Inspection on 03/01/06 for Ashdale Care Home

This inspection was carried out on 3rd January 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

Ashdale Care Home 17/01/07

Ashdale Care Home 24/10/05

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 3rd January 2006 9:00 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.V269508.R01.S.doc Version 5.1 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.V269508.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ashdale Care Home Address 42 The Park off Park Avenue Mansfield Nottinghamshire NG18 2AT 01623 631838 01623 631838 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.V269508.R01.S.doc Version 5.1 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. 24th October 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.V269508.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on 3rd January 2006 at 9am and was completed at 12. 40pm The registered manager was on day off but came into the home to participate in the inspection. The focus of the inspection was to assess the requirements and recommendations set at the previous visit and to assess any key standards not previously inspected over a twelve-month period. The methodology used included the examination of a sample of sections of two 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. The nurse, care staff and the cook and catering and domestic staff were spoken with as part of the inspection process. Observations were made of staff practices and interaction with service users, who mostly have limited communication and understanding. What the service does well: Service users have their needs assessed prior to moving into the home and have their needs reviewed. 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 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. 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. Ashdale Care Home DS0000024623.V269508.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: 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. Staff should undertake training in adult protection to ensure service users are fully protected from abuse. Attention is needed to ensure that water temperatures are regulated to a safe temperature of 43 degrees. The Environmental Health officer must be involved now in obtaining a resolution to the possible risk to service users from scalding. There are some areas for improvement in relation to quality monitoring and The registered provider must undertake his responsibilities as required by regulation 26 and a copy of the report held in the home for inspection. The manager does not work full time supernumery and only has two days rotered for management duties. There was evidence that the manager is working towards the ethos and expectations of the Care Standards Act 2000, however it is the professional opinion of the inspector that the service would be improved further should the manager work at least 90 of her allocated working hours on management responsibilities. The minor areas to address to improve the documentation and records pertaining to service users care and holistic daily records are ongoing. Ashdale Care Home DS0000024623.V269508.R01.S.doc Version 5.1 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.V269508.R01.S.doc Version 5.1 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.V269508.R01.S.doc Version 5.1 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 needs appear to be well met, however 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.V269508.R01.S.doc Version 5.1 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. The inspector discussed the above issues in detail with the manager, as this was an outstanding requirement from the previous inspection. It became apparent when discussing staff rotas that the manager only has two days a week top spend on management duties and the manager reported that the providers have had some personal issues to attend to, therefore the target date for this requirement has been extended. The Inspector advised that the provision and criteria for a Statement of Purpose and Service User Guide are specific within the Care Home Regulations 2001 and the Manager demonstrated a commitment to ensuring this is completed by the next timescale. 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. The manager demonstrated a commitment to reviewing the assessment documentation as above and to include evidence of service users preferences, likes /dislikes for daily living activities, such as bedtimes, etc. Care plans include the service users wishes for the end of life, and there is a section for religious, cultural and spiritual needs. At the previous inspection there was no indication within the documentation that service users had been risk assessed for bedroom door keys, however the manager provided evidence at this visit that this had been undertaken for some service users, but the information archived. It is recommended that this documentation, be included in the main working care plan and be included alongside a signature from the service user or relative that they have been issued with a copy of the service user guide. Ashdale Care Home DS0000024623.V269508.R01.S.doc Version 5.1 Page 11 Observation of staff interaction and practices confirmed that the staff team were attentive 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. Staff was observed to use mobilising equipment appropriately. 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 manager reported that she was clear about the registration status for the home and that only service users whose needs fall within this status are admitted. There were no issues in relation to the registration of the home at this visit and it was suggested that the two of the conditions of Registration set by the previous Inspectorate could possibly be removed as possibly not applicable under The Care Home Regulations 2001. The Registered Provider may wish to consider requesting these to be removed. Ashdale Care Home DS0000024623.V269508.R01.S.doc Version 5.1 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 Service users health, personal and social care needs are generally set out in the care plan and service users health care needs are met. The medicines management system is satisfactory. EVIDENCE: The care plans examined were well documented, comprehensive, and 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 evident in most care plans, however documentation of service users/relatives involvement and consultation could be further improved. 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 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 and on occasions lack of cross referencing of medical visits. The manager acknowledged some gaps in record keeping by staff and reported that she had reminded staff that these must be completed and staff must take Ashdale Care Home DS0000024623.V269508.R01.S.doc Version 5.1 Page 13 individual responsibility for completing records under The Act. The manager reported that she would consult with the staff team to look at better ways of working to ensure that all records and documentation are completed on a daily basis. The manager ensures that daily logs are always completed for each service user to provide evidence of staff attention/input and observations. Assessments were in place for tissue viability, mobility, infection control and nutrition. 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. After discussing this issue with the manager, it was evident that evaluation and action is taken, however the documentation was not fully in place to support these actions. The manager stated that she would review the current system and look at ways to prompt staff to record information accordingly. 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. Wound care appears to be well managed and documented. A medication round was observed and it was noted that medication administration and records were satisfactory. Training was arranged, to be provided for staff, by Boots the following day after the inspection. Ashdale Care Home DS0000024623.V269508.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,15 Service users are generally are helped to exercise choice and control over their lives, improved evidence of this is needed. There is improvement in the meal options provision and records of nutritional intake, which benefits service users, and further improvement is recommended. There is some evidence that service users lifestyle expectations and preferences are considered and a programme of activities provided but improved consultation and documentation is recommended. EVIDENCE: The manager reported that she organises activities which includes, a fortnightly music to movement sessions facilitated by an outside person an, organist and sing-along. No trips were arranged this summer but it is hoped this year a boat trip will be on offer. The manager reported that an advertisement for an activities co-ordinator is with the job centre and has been unsuccessful in recruiting a suitable person for some time. Hobbies and interests are obtained on admission, but due to the lack of motivation of service users, sometimes staff, find difficulty in organising activities. It was discussed that perhaps the responsibility may be delegated to one member of staff to co-ordinate and innovate activities. The documentation regarding Ashdale Care Home DS0000024623.V269508.R01.S.doc Version 5.1 Page 15 activities participation, by service users is not always completed and the responsibility for this should also be reviewed. The service users were enjoying breakfast on the arrival of the inspector and lunch on completion of the inspection, 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 meals provided appeared nutritional, well presented and appetising. The manager intends to improve the assessment documentation to include service users preferences of daily lifestyle and routines. The lunchtime menu provided two options and the cook was observed obtaining service users preferences. Evidence was also provided of meal options taken and the cook reported that she was due to review the menu and would be attending training on nutrition. The inspector and the cook discussed various ways to explore communication aids and alternative meal options. Ashdale Care Home DS0000024623.V269508.R01.S.doc Version 5.1 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 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 can be 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: There was a copy of the Nottinghamshire Committee for the Protection of Vulnerable Adults Guidance observed in the home. Staff have not undertaken training in adult protection apart from the brief coverage in their NVQ training. It is recommended that this be arranged. A complaints policy is displayed in the entrance hall and meets with the standard. The complaints records were not examined at this inspection. The manager reported that she has a good relationship with relatives and service users and any issues are discussed and resolved at the time. Ashdale Care Home DS0000024623.V269508.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19-26 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 water temperatures are regulated to a safe temperature of 43 degrees and it is recommended that the carpet on the first floor hallways be replaced. EVIDENCE: Ashdale Care Home DS0000024623.V269508.R01.S.doc Version 5.1 Page 18 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. 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. The manager stated that she did not feel this would benefit the current group of service users who in the main require staff assistance to use the facilities. 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. The hallway carpet on the first floor is looking shabby and has been taped to make safe around the fire exit area where it has become a trip hazard, it is recommended that the carpet be replaced. 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 57 degrees which may pose a risk to service users. There was no ‘hot water’ notice on this particular outlet either. The bedroom outlet tested at 48 degrees. See standard 38. 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 was evidence of gloves available in the laundry room and staff was observed to wear protective aprons. The home was clean and free from malodour. Ashdale Care Home DS0000024623.V269508.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The numbers and skill mix of staff is meeting Service user’s needs and a high proportion of staff are undertaking NVQ training. The homes recruitment policy and practices are satisfactory. 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, 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 manager works two days a week only on management tasks and despite the home being fairly well organised there were certain areas of the Care Home Regulations 2001 and the National Minimum Standards that had not been achieved/ met under the responsibilities of a Registered Manager. The inspector felt that in order for the manager to undertake her responsibilities and ‘manage’ the home effectively that she should work 90 - full time supernumery. There is also a deputy manager employed and it is recommended that all senior staff are made familiar with the expectations of the Care Standards Act, its associated Regulations and National Minimum Standards and are encouraged to take on delegated responsibilities in working towards the ethos. There has been no new staff employed since the previous inspection. Recruitment issues identified in the last report are now resolved. Ashdale Care Home DS0000024623.V269508.R01.S.doc Version 5.1 Page 20 Staff training records, were available and 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. The manager is to due to book this soon and agreed to provide evidence of this. Training records evidenced 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. Four staff have achieved NVQ2 status and six staff are currently working towards the qualification. Once all staff have achieved this will meet the standard of 50 staff holding NVQ. One staff member is currently progressing NVQ3. There are some reported assessor difficulties, which have delayed the completion of some staff qualifications. Ashdale Care Home DS0000024623.V269508.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,36,37,38 There needs to be more evidence of implementation of quality monitoring systems by the registered provider and registered manager to ensure the home is run in the best interests of service users and meet with the standards and regulations fully. Staff are appropriately supervised but should have six sessions a year provided. Service users rights and best interests are generally safeguarded by the homes record keeping policies and procedures. The health and safety and welfare of service users and staff are not fully promoted and protected in relation to the water outlet temperatures, which appear to be still problematic. EVIDENCE: Regulation 24, requires that the registered person shall establish and maintain a system for a] reviewing at appropriate intervals and b] improving the quality of care provided at the care home, including the quality of nursing where nursing is provided at the care home. Ashdale Care Home DS0000024623.V269508.R01.S.doc Version 5.1 Page 22 2,The registered person shall supply to the Commission a report in respect of any review conducted by him for the purposes of paragraph [1] and make a copy of the report available to service users 3, The system referred to in paragraph [1] shall provide for consultation with service users and their representatives. There was no evidence of quality monitoring available for the previous inspection or at this visit. The manager confirmed verbally and there was some evidence at this inspection that service users were being consulted and that relatives were involved in care reviews [this needs expanding further though]. A service users survey had been devised sometime ago but had not been utilised for some time. It is recommended that a simpler version be devised and implemented. The inspector had discussed Sunday Lunch choice issues to be put service users as a start and general questions about meals and quality of food provision as a starter. There are no service user/ relative meetings held currently and it is recommended that these be arranged with some activity, such as just for an example, a cheese and wine evening to encourage relatives to participate and contribute ideas. The registered provider visits the home regularly and the manager keeps a record of provider visits, however this does not meet with the provider’s responsibilities under Regulation 26 and this is required. Regulation 37 notifications are made to the Commission regarding notification of death or events which effect the health and well being of service users etc, however it is recommended that copies of these be kept in the home and available for inspection, should the original not be received at CSCI Evidence was provided that the manager has started to undertake formal supervision with staff, however if more management time allocated this would ensure that supervision standards of 6 sessions a year would be met. The deputy manager or other senior staff could be utilised in the supervision process. There were some identified areas for improvement in record keeping, such as the water outlet temperature tests, which were documented last tested in July 05 and in daily communications by staff in relation to activities and care plan updates. Care plans were observed to be secure in the office with the door also locked. The fire safety test records were examined and found to be satisfactory Emergency lighting tests were now evidenced as being carried out monthly The health and safety practices overall appeared to be fairly satisfactory. The There was now evidence of a fire safety risks assessment. During the inspection one washroom/toilet was prohibited from use until further notice due to the high risk of scalding from the washbasin hot tap. A Ashdale Care Home DS0000024623.V269508.R01.S.doc Version 5.1 Page 23 requirement is made that the Environmental Health Officer be consulted promptly for advice regarding a resolution to the issue. Ashdale Care Home DS0000024623.V269508.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 1 X X 3 2 2 Ashdale Care Home DS0000024623.V269508.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 Requirement 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 Previous timescale 24/12/05 Not Met Provide evidence that all existing service users have been issued with a service users guide Previous timescale 24/12/05 Not Met Timescale for action 24/02/06 2. OP1 5 24/02/06 3 OP25 12, 13,1 6, 23 Ensure the hot water is regulated 24/02/06 to a safe temperature in communal water outlets Previous timescale 24/12/05 Not Met Ensure records are up to date in relation to monthly checks of water outlet temperatures. 4 OP30 18 Ensure all food handlers undertake food hygiene training [including care staff] Target date not yet due. [Evidence of the course booking must be sent to DS0000024623.V269508.R01.S.doc 24/01/06 Ashdale Care Home Version 5.1 Page 26 the Inspector as evidence that this is being addressed by the due date.] 5 OP33 24 The Registered Provider must ensure that a quality monitoring system is in place and provide evidence that the requirements of Regulation 24 are being met. Further development must be made regarding consultation with service users/relatives as part of this process. 6 7 OP37 OP38 17 12,13,16, 23 Ensure all records are up to date. Consult with the Environmental Health Officer for advice to resolve the ongoing issue of high water outlet temperatures in some areas and report the outcome to the inspector. The Registered Provider must undertake his responsibilities as required by regulation 26 and a copy of the report held in the home for inspection. 24/02/06 24/01/06 24/02/06 8 *RQN 00 24/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP3 Good Practice Recommendations Expand the assessment document to include the topics listed in Standard 3.3 Keep records for service users issue of bedroom door keys and lockable facilities in the main care plan folder alongside any risk assessments that state the service user is unable to hold keys. Ashdale Care Home DS0000024623.V269508.R01.S.doc Version 5.1 Page 27 2 OP8 Include a history of falls record in the service users care plan and use the information to evaluate the events and prevent further occurrence. Further develop the activities provision as specified in the report and ensure staff keep appropriate records of participation. Provide training for staff for adult protection. Replace the hallway carpeting on the first floor. In order for the manager to undertake her full responsibilities as a registered manager for the home she should work supernumery 90 of the time. Provide evidence of an annual training plan and ensure this is available for inspection or an easy reference document to identify training needs and provision. Formal supervision sessions should be expanded to six sessions a year for each member of the care team. Keep copies of regulation 37 Notifications in the home Improve the record keeping practices in the home. 3 4 5 6 7 OP12 OP18 OP19 OP27 OP30 8 9 10 OP36 OP37 OP37 Ashdale Care Home DS0000024623.V269508.R01.S.doc Version 5.1 Page 28 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.V269508.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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