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Inspection on 13/04/06 for Ashdown Nursing Home

Also see our care home review for Ashdown Nursing Home for more information

This inspection was carried out on 13th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Some staff were observed to be caring in their approach to residents. Activities and special events are held at the home, which the staff try to tailor to individual residents known preferences. Visitors to the home say that they are made to feel welcome and one relative spoken with during the visit felt that they were kept informed about changes in the health of their relative living at the home.

What has improved since the last inspection?

An assessment of need had been undertaken for the one resident who had moved into the home since the last inspection. This and other assessments viewed had some good information in them. Staff records have improved to ensure that homes recruitment practice protects residents. The cleanliness of the kitchen has much improved and a chef is now employed for five days a week with the other two days being covered by another employee who has a food hygiene certificate. There have been improvement to the records of what residents choose to eat but these are not always completed and do not indicate what alternatives have been given.

What the care home could do better:

Information gathered at assessment prior to moving into the home should be transferred to a plan of care to assure that assessed needs are being followed up. All visitors to the home should be reminded to enter their visit in the visitors book as a matter of security, health and safety and protection of residents living at the home. The registered person must provide Adult Protection training for all staff working at the home. At the moment 50% of staff have attended the training.Persons left in charge of the home should be familiar with the location of all records which may be requested at inspection. The complaints records were not available to the inspectors at this visit. Some areas of the environment are in need of redecoration and some bedroom furniture needs to be replaced. Some practices, environmental issues and lack of documentation do not protect the health, safety and welfare of the residents.

CARE HOMES FOR OLDER PEOPLE Ashdown Nursing Home 2 Shakespeare Road Worthing West Sussex BN11 4AN Lead Inspector Mrs D Peel Unannounced Inspection 13th April 2006 10:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ashdown Nursing Home DS0000062422.V289347.R02.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. Ashdown Nursing Home DS0000062422.V289347.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ashdown Nursing Home Address 2 Shakespeare Road Worthing West Sussex BN11 4AN 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) 01903 211846 Newcare Homes Limited Post Vacant Care Home 40 Category(ies) of Dementia (40), Mental disorder, excluding registration, with number learning disability or dementia (40) of places Ashdown Nursing Home DS0000062422.V289347.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. A maximum of forty Service Users may be accommodated. Service Users in the category mental disorder may only be admitted if they have an associated dementia illness and are over 65 years of age. 13th September 2005 Date of last inspection Brief Description of the Service: Ashdown Nursing Home is situated in a residential area of Worthing in West Sussex. The registered providers are Newcare Homes Ltd who purchased the home in 2004. The Registered Managers post is vacant at present and the providers continue to advertise the vacancy. Ashdown is registered for 40 residents over the age of 65 years who have dementia. The Statement of Purpose states that the home has 3 en-suite bedrooms, 16 single rooms and 12 shared rooms. Resident’s accommodation is on ground and first floors. Communal areas consist of a lounge on the ground floor and a second lounge on the first floor. There is a small dining room adjacent to the lounge on the ground floor. There are other small sitting areas in the entrance hall and upper and lower corridors, which lead to bedrooms. A passenger lift is available for rooms on the upper floor. There is a garden to the rear of the property, which is not currently available for use by residents. Not all of the single rooms bedrooms meet The National Minimum Standards for Older People, however the Commission for Social Care Inspection (CSCI) have been informed that this will be addressed with the future planned improvements for the home. Ashdown Nursing Home DS0000062422.V289347.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Mrs Diane Peel and Miss Helen Tomlinson carried out this unannounced inspection over 6 hours on the 13th April 2006. Two additional visits were made to the home on the 11th November 2005 and 30th January 2006 to monitor compliance with Statutory Requirements included in the last inspection report dated 13th September 2005. Immediate requirement notices were left at both the monitoring visits, as requirements had not been fully met. Additional visit letters sent to the registered person following these visit can be obtained from the Commission for Social Care Inspection (CSCI) office on request. The responsible individual, Mr Beeharee, met with Mrs Jan Foley, Regulation Manager and Mrs Ann Peace, Regulatory Inspection on the 14/12/05 at Ridgeworth House to discuss a plan of improvement for the home. Prior to this visit to the home the inspectors reviewed previous inspection reports and communication from the providers in response to requirement notices being issued following the visits on the 11th November 2005 and 30th January 2006. A case tracking exercise for four residents was undertaken to look at how the assessed needs of this group of residents with diverse needs were being met. The inspectors met all twenty two residents living at the home during the visit but none of the residents were able to express an informed opinion of what it was like to live at the home. The records of three staff were inspected and staff were spoken with informally during the visit to find out what it is like to work at the home. The inspectors took the opportunity to speak to two of the four visitors who visited the home during the inspection. Samples of other records required to be kept by the home were viewed during the visit to ensure that the providers are meeting their obligations with regard to the administration of the home. Following the inspection visit social services were contacted with regard to one resident whose needs were not being appropriately met by staff at the home. Some improvements have been made since the last visit to the home. Ashdown Nursing Home DS0000062422.V289347.R02.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Information gathered at assessment prior to moving into the home should be transferred to a plan of care to assure that assessed needs are being followed up. All visitors to the home should be reminded to enter their visit in the visitors book as a matter of security, health and safety and protection of residents living at the home. The registered person must provide Adult Protection training for all staff working at the home. At the moment 50 of staff have attended the training. Ashdown Nursing Home DS0000062422.V289347.R02.S.doc Version 5.1 Page 7 Persons left in charge of the home should be familiar with the location of all records which may be requested at inspection. The complaints records were not available to the inspectors at this visit. Some areas of the environment are in need of redecoration and some bedroom furniture needs to be replaced. Some practices, environmental issues and lack of documentation do not protect the health, safety and welfare of the residents. 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. Ashdown Nursing Home DS0000062422.V289347.R02.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 Ashdown Nursing Home DS0000062422.V289347.R02.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): 3,6 Residents had their needs assessed prior to admission to the home. Some of the information obtained was not included on the plan of care. In those records viewed there was no evidence that prospective residents were assured their needs could be met. Standard 6 is not applicable to Ashdown Nursing Home. Outcomes for residents are poor. EVIDENCE: The records for four residents were examined in detail and others were read to obtain specific information. Assessments of the resident’s needs, which had been carried out prior to admission, were seen. This information had then been transferred to an assessment, which was done when the resident was admitted to the home. Some of this information was detailed and all aspects of daily living were included. In some instances important information included on these assessments had not been transferred to a plan of how to meet these needs. This included information about aggressive behaviour of residents and Ashdown Nursing Home DS0000062422.V289347.R02.S.doc Version 5.1 Page 10 past history of depression. This information could impact on their current needs. There was no evidence in those records viewed that the residents or their representatives were assured that the needs of the residents could be met by the staff and facilities at the home. Ashdown Nursing Home DS0000062422.V289347.R02.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5,8,9,10 Residents had a plan of care documented. Those seen did not contain sufficient information of how all the resident’s needs should be met. The health care needs of the residents were assessed and identified but were not fully met. The residents were not fully protected by the procedures for administering and recording medication. Some practices compromised the dignity of the residents living at the home. Outcomes for residents are poor. EVIDENCE: Residents had a plan of care recorded. This included various aspects of daily life such as personal hygiene and mobility. There was some information regarding the specific mental health issues for the residents, however this varied in detail. There was a lack of documented actions required to meet the identified needs of the residents. For one resident who was declining to eat Ashdown Nursing Home DS0000062422.V289347.R02.S.doc Version 5.1 Page 12 meals, there was no revised care plan and no information as to how to ensure this resident had the nutrition they required. For another who was physically and verbally aggressive to staff there was some information of how to manage this on file. In practice staff did not use the approach documented. For one resident who shouted out for most of the day it was documented that they should spend time in the lounge with other residents. In practice this resident was isolated in a small annexe to another resident’s bedroom, for the duration of the visit. One resident who walked around the home throughout the day, was told by staff to sit down constantly. No effort was made to assist this resident in any other way despite their behaviour indicating a reason for this restlessness, which may have been ill fitting continence wear. Assessments of health care needs, such as risk of pressure sore development, were on file. For one resident this assessment had not been reviewed since December 2005. The last recorded plan of care stated this resident should have their position changed two hourly. During the visit they remained in the same position. On speaking to staff this resident was moved twice during the day to be assisted to use the toilet and it was agreed the documented plan of care was not being met. Nutritional risk assessments were on file. For one resident who was diabetic and declining to eat meals, this had been reviewed in the past month, but contained incorrect information. The documented assessment stated the resident had a good appetite and ate most of three meals per day. Other records showed this had not been the case for at least one month. On speaking to staff they were aware of the resident’s reluctance to eat, but the approach to this varied between the staff. There was insufficient information to indicate this resident’s nutritional needs were being met. . The medication was administered to the residents by the qualified nurses working in the home. At the time of this visit no residents were administering their own medication. The storage of medication was appropriate and safe. Two medication administration trolleys were in the home and both were secured. The administration sheets for several residents were examined. These showed that some medication prescribed on a regular basis had not been given to the residents. Staff confirmed that residents were no longer prescribed this medication, but the printed administration sheets had not been amended. There was no indication on the sheets as to who had ceased the medication and when. The administration sheet for one resident indicated they had been given prescribed medication the morning of the visit. This medication was not available in the home and had not been received into the home for nine months suggesting that another residents identical medication had been used. Ashdown Nursing Home DS0000062422.V289347.R02.S.doc Version 5.1 Page 13 The sign to indicate oxygen was stored in the room was not displayed. Some controlled medication which was no longer in use was present in the home. External preparations, such as creams, had not been signed as given on the administration sheets. One resident had been prescribed strong pain relief for a short period. This had run out on the day of the visit and no further pain relief was prescribed for this resident. Staff were unaware that the bank holiday period would mean this resident could not be prescribed anything for at least four days. Consideration to appropriate pain relief must be part of the resident’s care. Some practices in the home did not protect the resident’s dignity and privacy. There were no locks on the bathroom or toilet doors or any other way to indicate they were in use. Staff were observed to enter resident’s bedrooms without knocking. The inspectors observed that some staff did talk to the residents in a respectful manner whilst others were impatient with repeated behaviours from the residents. Ashdown Nursing Home DS0000062422.V289347.R02.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): 12,13,14,15 Residents that are able are encouraged to maintain contact with their family and friends so that they can satisfy their social and emotional needs. The social activity programme is flexible to cater for individual residents abilities and to offer variation to daily living. Systems for monitoring dietary needs do not ensure that all residents’ nutritional needs are being met. Food provided was of an adequate standard but alternatives were not satisfactory. Outcomes for residents are poor. EVIDENCE: Due to the frailty of the residents living at the home residents rely on the flexibility of staff. On the day of the visit all residents except one were sat in one of the lounges or for one resident a separate annex area, for most of the day. Ashdown Nursing Home DS0000062422.V289347.R02.S.doc Version 5.1 Page 15 After lunch staff assisted some residents to take part in activities such as looking at books, knitting and colouring/drawing and nail care. There was a notice posted on the upstairs notice board, which advertised the activities for the week commencing 3/4/06 as: aromatherapy, bingo, dominoes, drawing/colouring and puzzles. Records are kept of activities, which each resident participate in, and these showed that in addition the home has music therapy sessions, aromatherapy, and church services. Also recorded are occasional special events which staff and visitors are invited to. An example of this was a Mothers day celebration held on the 25th March when a light supper was provided. There were five visitors to the home during the day. Two were spoken with. Both felt that they were made to feel comfortable by the friendly manner of the staff. One visitor spoken with commented that they had assisted their relative to choose Ashdown after visiting another three homes, finding this home to be better than the others. The visitor’s book in use at the home does record some regular visitors to the home but not all visitors are being recorded because during the period of the visit four visitors arrived and only one was recorded in the visitors book. The inspectors joined residents for the main meal of the day and observed that some residents were waiting a long time before being assisted. Consideration needs to be given to how meals are served and how are residents assisted with their meals. The meal sampled by the inspectors was of an adequate standard but the potatoes lacked flavour and some residents left their meal. The records of food provided at the home have improved but there was not always completed on a daily basis so a complete record was not available. It was recorded if residents had not eaten a full meal and in some instances any alternative was documented. These alternatives were often cornflakes. There had been no advice sought from other professionals regarding the nutritional needs of the residents, despite risks having been identified by staff. Ashdown Nursing Home DS0000062422.V289347.R02.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): The complaints procedure is clear and enables those using the service to have the confidence that their complaint will be responded to within a maximum of 28 days. Not all staff had attended adult protection training to ensure that they are fully aware of their responsibility to recognise and report abuse. Outcomes for residents are adequate. EVIDENCE: There is a clear complaints procedure on display in the entrance hall assuring residents, relatives and visitors that all complaints will be taken seriously and acted upon. On the day of this visit an inspector asked to see records of complaints but these could not be located. Staff training records viewed showed that 50 of the staff had attended formal adult protection training on the 24th November 2005. Ashdown Nursing Home DS0000062422.V289347.R02.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): 19,20,21,22,23,24,25,26 The overall general appearance of the home is that it is basic and lacks care and attention. Furniture in bedrooms look tired and some bedrooms have unpleasant odours. The outdoor space is not safe or pleasant for residents to use. Outcomes for residents are poor. EVIDENCE: At the last inspection the home had been redecorated and some new carpets had been laid. During this visit to the inspectors carried out a full tour of the home visiting all communal and private accommodation used by residents. Ashdown Nursing Home DS0000062422.V289347.R02.S.doc Version 5.1 Page 18 The communal lounges had a good standard of furniture in them and the downstairs lounge and entrance hall looks homely. Bedrooms are basic with some furniture looking tired. Some beds, which do not have fitted footboards, have ill-fitting mattresses, which over hang the end of the bed. Several of the bedrails were ill-fitting and could present a hazard to residents getting limbs trapped. They were loose and moved away from the mattress leaving a gap and one could not be secured in the “up” position. The bed frame in bedroom ten was rusty and would not be able to be cleaned properly to ensure good infection control. The bathroom floor covering in the bathroom accommodating the parker bath on the ground floor is split and is an infection control hazard because it cannot be cleaned properly. The frame around the toilet near to bedroom three was rusty and is an infection control hazard. The patio area outside the fire door leading from the corridor near to bedroom nine was covered in moss and would be a danger to staff and residents in an emergency evacuation of the building. Some bedrooms and bathrooms were being used to store equipment which could be a hazard to residents. One bedroom door was not easy to open or close, and another bedroom door had the fire seal hanging off. Both the door to the sluice on the ground floor and first floor had been left unlocked. A commode with dried on faeces had been left in the down stairs sluice and a large bottle of cleaning fluid was on the floor. This should be kept in locked cupboard. The environmental officer visited the home on the 10/2/06 and made a number of recommendations for improvement to the kitchen and storage areas. At this inspection by CSCI inspectors it was noted that the kitchen was a much cleaner environment for the preparation of residents meals. Ashdown Nursing Home DS0000062422.V289347.R02.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): 27,29,30 The skills mix of staff is not sufficient to meet the mental health needs of the residents. Recruitment documentation and staff records have improved and now protect residents. Outcomes for residents are poor. EVIDENCE: The home has a training programme in place which provides the majority of skills to meets residents needs however there was no evidence that any staff had attended Dementia Training although one member of staff commented that they had done a one day course. The records of four were viewed at this inspection and were observed to be in good order and showed that recruitment practice had improved to protect residents living at the home. Ashdown Nursing Home DS0000062422.V289347.R02.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,37,38 Management systems within the home do not ensure that residents receive a service which meets its stated purpose and aims and objectives. There are no thorough systems for reviewing the quality of care delivered to the residents in the home. Some practices, environmental issues and lack of documentation do not protect the health, safety and welfare of the residents. Outcomes for residents are poor. EVIDENCE: No manager has been appointed although the director present at the home during the visit was able to demonstrate that the company had advertised the vacancy and that the company continues to try to recruit a manager. Ashdown Nursing Home DS0000062422.V289347.R02.S.doc Version 5.1 Page 21 The acting manager was not present in the home. Staff who were present were unaware of any systems for reviewing the quality of care provided to the residents. Some questionnaires had been received from relatives in January. These contained both positive and negative comments. There was no evidence of any action taken as a result of this survey. Inspectors found that infection control, understanding infection control and putting measures into place were absent, as there were many issues identified in bedroom bathrooms and other area of the home. Records of accidents were kept in the home but it was noted that there had been three accidents to residents since the beginning of January 2006, resulting in residents attending accident and emergency department at the local hospital. These accidents had not been reported to the CSCI as required by Regulation 37 of the Care Homes Regulation 2001 as “any serious injury to a service user”. Daily records seen by an inspector recorded that residents had been treated for an outbreak of scabies. Staff confirmed that residents had been treated a few months ago. This had also not been reported to the CSCI as required by Regulation 37. Ashdown Nursing Home DS0000062422.V289347.R02.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 x 18 2 1 3 2 2 2 2 2 1 STAFFING Standard No Score 27 2 28 X 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x 1 x x x 1 1 Ashdown Nursing Home DS0000062422.V289347.R02.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14(1)(d)( 2) Requirement All residents must have an assessment of need which is kept under review and revised when circumstances change. The registered person must confirm in writing that the resident’s needs can be met in the home. All residents must have an up to date plan of care which includes the details of how their needs are to be met. All residents nutritional needs must be met. The mental health needs of the residents must be assessed and met. Advice from other health professionals must be sought and acted upon. All risks must be identified and assessed with management plans put into place. The administration, recording and storage of medication must meet the royal Pharmaceutical guidelines and the qualified nurses code of practice. The registered person must DS0000062422.V289347.R02.S.doc Timescale for action 08/06/06 2. OP7 15 08/06/06 3. OP8 12(1)(a) 08/06/06 4 5 OP8 OP9 13(4)(c ) 13(2) 08/06/06 08/06/06 6 OP10 12(4) (a) 08/06/06 Page 24 Ashdown Nursing Home Version 5.1 7 OP15 16(2) (i) 8 9 OP19 OP26 23(2) (b) 13(3) 10 OP26 13(3) 11 OP26 13(3) 12 13 OP30 OP31 18(c) (i) 8 14 OP33 24(2) 15 16 17 OP38 OP38 OP38 13(4) 13(4) 13(4) make sure the home is conducted in a manner which respects the privacy and dignity of residents. The registered person must provide in adequate quantities, suitable, wholesome and nutritious food which is varied and properly prepared and available at such time as may reasonably required by service users. The premises must be kept in good state of repair externally and internally. The floor covering in the downstairs bathroom must be repaired or replaced as a matter of infection control. The frame around the toilet near to bedroom three must be repaired or replaced as a matter of infection control. The bed frame in bedroom ten was rusty, it must be repaired or replaced as it would not be able to be cleaned properly to ensure good infection control. All staff must have training in Dementia awareness and Adult Protection. The providers must appoint a individual to manage the home and to apply for registration with CSCI The registered person must supply to the CSCI a report of outcomes to the homes review of quality of care provided at the home. Window restrictors in rooms 6 and 7 The fire door seal must be repaired in bedroom five The door to bedroom twenty five must be adjusted so that it can DS0000062422.V289347.R02.S.doc 08/06/06 08/06/06 08/06/06 08/06/06 08/06/06 08/06/06 08/06/06 08/06/06 08/06/06 08/06/06 08/06/06 Ashdown Nursing Home Version 5.1 Page 25 18 OP38 13(4) 19 20 21 OP38 OP38 OP38 13(4) 13(4) 37 22 OP38 13(4) open and close easily. The patio area outside the fire door leading from the corridor near to bedroom nine must be made safe Rooms housing the sluices must be kept locked when not in use Bedrails must be made safe or replaced Notifications required by Reg 37 must be submitted to the CSCI. Any incidents requiring notifications since the last inspection must be forwarded before the time scale for action date. Rooms being used by residents must not be used to store equipment. 08/06/06 08/06/06 08/06/06 08/06/06 08/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ashdown Nursing Home DS0000062422.V289347.R02.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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 Ashdown Nursing Home DS0000062422.V289347.R02.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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