Inspection on 09/07/08 for Ashdown Nursing Home

This inspection was carried out on 9th July 2008.

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

Ashdown Nursing Home 22/04/10

Ashdown Nursing Home 22/02/10

Ashdown Nursing Home 02/07/09

Ashdown Nursing Home 15/08/07

Ashdown Nursing Home 20/11/06

Ashdown Nursing Home 13/04/06

Ashdown Nursing Home 13/09/05

Ashdown Nursing Home 24/05/05

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Ashdown Nursing Home 2 Shakespeare Road Worthing West Sussex BN11 4AN Lead Inspector Annette Campbell-Currie Unannounced Inspection 09:45 9th July 2008 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.V367321.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ashdown Nursing Home DS0000062422.V367321.R01.S.doc Version 5.2 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 01903 208680 mgnewcare@googlemail.com Newcare Homes Ltd Post vacant Care Home 40 Category(ies) of Dementia (0), Mental disorder, excluding registration, with number learning disability or dementia (0) of places Ashdown Nursing Home DS0000062422.V367321.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home with nursing only - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) 2. Mental disorder, excluding learning disability or dementia (MD). The maximum number of service users to be accommodated is 40. Date of last inspection 15th August 2007 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. Ashdown is registered for 40 residents over the age of 65 years who have dementia. The Statement of Purpose continues to be updated to show the changes to the home as it is being refurbished. The improved communal areas consist of a lounge and a lounge/dining room on the ground floor and a second lounge on the first 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. The current scale of fees being charged at the home is from £600 to £700 per week. Ashdown Nursing Home DS0000062422.V367321.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is One Star. This means that the people who use this service experience adequate outcomes. Annette Campbell-Currie carried out the site visit for this key unannounced inspection over six and a quarter hours. Two requirements had been made at the previous inspection and progress has been made in addressing the issues raised including having a more flexible approach to some daily routines. The registered manager left in November and the proprietor, Mr Beeharee was acting manager until the end of May. A new manager began work in June and assisted with the site visit, all the information and paperwork we (the Commission) needed was available. There were thirty-one people staying in the home at the time. The proprietor had returned an annual quality assurance assessment form (AQAA) about the home and this was used in the planning of the inspection. Surveys about the service were received from three people living in the home and three staff. The information has been used in making an assessment of the service. The following documents were read: the case records for four service users, recruitment records for four staff, training records, quality assurance information, staff rotas, the complaints records and other relevant information. During the day three people living in the home, two visiting relatives and five members of staff were spoken with including the chef on duty. The outcomes for people living in the home were assessed in relation to twenty-one of the thirty-eight National Minimum Standards for the care of older people, including those considered to be key standards to ensure the welfare of people living in the home. Three requirements have been made following the site visit. What the service does well: The newly appointed manager is enthusiastic about her post and said that she is enjoying the work. The staff team on duty were very caring and one person living in the home said: “They are good staff and are all very kind to us”. There is a key worker system and staff are organised into small groups with individual responsibilities each day so that they are clear about their duties. This also means that people receive the care that they need each day. The care plans are detailed and provide guidance to staff about the way people should be supported. Ashdown Nursing Home DS0000062422.V367321.R01.S.doc Version 5.2 Page 6 The food was freshly made and well presented. People who returned surveys said they like the meals. The home was clean with no unpleasant odours. Progress is being made in upgrading the building. What has improved since the last inspection? What they could do better: The manager must ensure that case discussions are held in private so that confidentiality is protected; she agreed to make sure that a suitable room would be used for this purpose. All staff including the manager and activities coordinator should be provided with updated training in caring for people who have dementia to make sure they understand people’s needs. This was a recommendation following a safeguarding investigation carried out by The Social and Caring Services in March and has not yet been fully implemented. A requirement has been made about this matter. All staff should receive updated training in safeguarding vulnerable adults so that they are able to protect people living in the home. A requirement has been made regarding this matter. Staff who are in charge of the home should be familiar with the reporting procedures outlined in the West Sussex multi agency policy and procedure for safeguarding vulnerable people. A requirement has been made regarding this matter. Attention should be paid to providing an environment that is stimulating and assists people who have a dementia to understand and find their way around more easily. Ashdown Nursing Home DS0000062422.V367321.R01.S.doc Version 5.2 Page 7 Staff should be provided with hand-washing items in the sluice room to prevent the risk of cross infection. Information including the complaints policy and quality assurance documents should be provided in a format that assists people who have a dementia to understand and provide feedback about their care. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ashdown Nursing Home DS0000062422.V367321.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashdown Nursing Home DS0000062422.V367321.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have an assessment of their needs before a decision is made about them moving to the home. Ashdown Nursing home does not provide intermediate care. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) stated that when a referral is received the manager checks to make sure the person has a dementia and meets the registration requirements of the home. When social workers and care managers make referrals, the home receives a great deal of information to help them make a decision about whether or not they could meet the person’s needs. Ashdown Nursing Home DS0000062422.V367321.R01.S.doc Version 5.2 Page 10 The manager carries out a pre-assessment either in the person’s home or in hospital and on the day of the visit the manager had gone out to carry out two assessments; she said that relatives would also be involved in this process. The case records of four people living in the home were seen including two people who had been recently admitted. The pre-assessments were on file and included some social history as well as details of the person’s medical and social care needs. Ashdown Nursing Home DS0000062422.V367321.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each person’s health, personal and social care needs are set out in an individual plan of care. People’s health care needs are met. The medication procedures protect people who are living in the home. People feel they are treated with respect however their privacy is not protected at all times. EVIDENCE: There is a care planning and risk assessment process in place. Samples of case records were read and showed that a detailed plan of care had been drawn up. Health and personal care needs were noted and guidance to staff about the way care should be provided. There was space to include religious and spiritual needs and choices. There was some detail about people’s life history and interests and the activities coordinator is gradually gathering more information. Risk assessments had been carried out and possible risks identified. Where behavioural risks had been noted clear guidance about the way to minimise risks and approach people had been documented. There was also some printed Ashdown Nursing Home DS0000062422.V367321.R01.S.doc Version 5.2 Page 12 guidance on case records to help staff understand how to manager certain risks. Key workers are responsible for keeping care plans updated and all the staff spoken with said that they understand people’s needs. It was evident that care plans and risk assessments had been reviewed to make sure any changes were identified. The daily recording sheets showed that key information is passed between staff daily and at night and any changes noted. There was some evidence to show that relatives had been involved in the care planning and review. There was evidence on the day that when people have increasing health care needs they are supported to stay in the familiar surroundings of their home with the additional health care they need. Health care needs were clearly documented and where daily input is required for example for people who have diabetes this was also logged on the daily task sheets for staff. It was clear that GPs and other health care professionals visit as required to provide consultations. Visits from the community psychiatric nurse had been noted on some case records. The assessment and guidance from a speech and language therapist was noted in one care plan. People have access to a chiropody service. There were fluid and nutrition charts for people where a need had been identified. Everyone has his or her weight checked each month so that this can be monitored. Wound care is logged and monitored; the manager said she is going to review the way that wound care is documented using body charts to make sure progress can be more clearly measured. It was suggested to the manager that the guidance of a physiotherapist should be sought regarding supporting people when they are sitting to make sure they are not in an uncomfortable position. The medication storage and recording systems were seen and were in order. There is a lockable medication fridge however the temperatures have not yet been monitored to make sure that it is kept at the required temperature. The nurse on duty said updated medication training is provided as required and this keeps her knowledge and skills up to date. It was clear that people have regular medication reviews to make sure that they are being prescribed the correct amount of medication to meet their needs. Care staff are provided with guidance at induction about the way to provide personal care. The care plans also included guidance about the way people like their care to be provided. Staff were observed to be assisting people in a quiet, patient and sensitive way. There is a weekly case discussion that is lead by the key worker and facilitated by the manager. This provides useful background information and ensures that all staff are clear about the things that are important in each person’s life. At the time of the visit this meeting was held in the communal area and could be heard by everyone else in the room. In order to protect confidentiality and privacy the manager was advised to make sure that this meeting is held in a more private setting. The manager agreed to use a more private room for this meeting in future. Ashdown Nursing Home DS0000062422.V367321.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People find that some of the lifestyle experience matches their expectations. People are supported to maintain contact with their family and friends. People have some choice in their daily lives. A nutritious and balanced diet is provided. EVIDENCE: An activities coordinator has been appointed recently and works each day from 10am until 2pm. She is enthusiastic about setting up a programme of activities and has gathered some articles about working with people who have dementia although she has not yet had the opportunity to attend any specialist training. There is some information on case records about people’s life history and interests although those seen were not detailed. The activities coordinator is also researching people’s backgrounds with their help and the help of relatives; this is more difficult for people who do not have contact with their families. There is a programme of activities and this is planned weekly. There was a baking activity during the day of the visit and two people were involved in this during the morning. The other people in the home were not involved in Ashdown Nursing Home DS0000062422.V367321.R01.S.doc Version 5.2 Page 14 activities and were sitting in the two lounges, some were dosing. The manager said that people like to go outside in good weather. The coordinator said that she speaks to everyone individually each day and tries to spend some one-toone time with some people. Consideration should be given to providing a range of activities to meet individual need and to support care staff to provide small group or one-to-one time so that individual needs can be accommodated. Visitors are welcome in the home and the relatives spoken with said that they are always made welcome and staff are very kind. Visitors can also stay to have a meal with their relative if they wish. Birthdays are celebrated and family and friends invited if appropriate. Anglican and Catholic Church services are held and some people are visited by their priest. People are supported to make some choices in their lives and breakfast and supper times are more flexible. Consideration should be given to finding ways that support people who have a dementia to make choices for example by the use of picture cards. The newly appointed manager has reviewed and updated the menus; she is committed to ensuring that people have a healthy and nutritious diet. Meals are freshly cooked on the premises and fresh local produce is used. There was a choice of hot meal on the day of the visit. People had been asked to make a choice the evening before but the manager said it would not be a problem if they changed their mind on the day. People were being asked in the morning what they would like for supper. The use of picture cards to assist people to make choices about their food is being considered. The food was well presented and appetising. People were provided with a choice of two cold drinks a lunchtime. Eight people were sitting at the two tables that are provided and everyone else was sitting in the lounge. There is no separate dining area upstairs and so those who stay upstairs during the day sit in chairs in the lounge with trays in front of them. Consideration should be given to providing better dining room facilities so that people can sit up at meal times so that they are more sociable occasions. Special diets are catered for and soft food was well presented and looked appetising. Not all those assisted with eating were being spoken with so that they would know what they were eating. This was discussed with the manager who said she would make sure that staff understand the importance of this. Ashdown Nursing Home DS0000062422.V367321.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints policy is not provided in a format that would assist people who have a dementia. The procedures in the home do not fully protect people. EVIDENCE: There is a copy of the complaints policy in the hallway. This is not provided in a format that would assist people who have a dementia to know what to do if they want to make a complaint. The policy should include a timescale for investigating complaints and the contact details for the Commission should be updated. The record of complaints were seen and showed that complaints that had been made have been investigated. There are policies regarding safeguarding adults and the home follows the guidelines set out by the West Sussex multi-disciplinary safeguarding policy and procedure. The Social and Caring Services carried out a safeguarding investigation in March following an allegation that was not substantiated, however recommendations were made to the home at the time to ensure that people are fully protected. Some of the recommendations have been implemented; it was not clear that dementia training for staff has been prioritised as recommended to ensure that staff understand how to protect those who have a dementia. A requirement has been made about this matter. Ashdown Nursing Home DS0000062422.V367321.R01.S.doc Version 5.2 Page 16 Staff training regarding safeguarding vulnerable adults is available however it was unclear from the records that all staff have undertaken this training in the past twelve months. A requirement has been made about this matter. All staff spoken with were clear about the need to protect people from abuse. The manager was clear about her duty to report any safeguarding concerns however another member of staff who at times would be in charge in the home was unclear about reporting procedures. A requirement has been made regarding this matter. Ashdown Nursing Home DS0000062422.V367321.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People live in an environment that is well maintained. The home is clean however not all areas of the home ensure that people are protected from cross infection. EVIDENCE: There have been improvements to the decoration of the home including a number of bedrooms and communal areas. A new wet room has been built and the outside patio area is now safe and well used in good weather. Areas that need further improvement include the toilet downstairs for the use of people living in the home. There are plans to improve the laundry facilities. The garden at the back of the house is not yet suitable or safe for people to use; the manager said that contractors have been employed to clear the area and make it safe. Ashdown Nursing Home DS0000062422.V367321.R01.S.doc Version 5.2 Page 18 The conservatory was built without the required planning permission. The home have been given time to re-apply for permission from Worthing Borough Council for the structure to remain in place. Two of the bedrooms seen were very bare and the manager said the home depends on relatives bringing personal items in. There are handrails in some areas of the home and it would assist people with poor mobility to get around if handrails were to be provided in all corridors. Consideration should be given to providing an environment that is suited to the needs of people who have a memory problem. The use of pictures and sign posting as well as sensory areas would improve the quality of life for people living in the home and help them to understand their environment better. Some bedrooms had photographs on the door however these were placed high so that they would not be easily seen to assist residents recognise their own room. Consideration could be given to the arrangement of seating in the large lounge to make the atmosphere more homely. Dedicated staff are employed for kitchen, cleaning and laundry duties. Additional hours have been provided for housekeeping duties as the need was identified. There are two sluice rooms, one on each floor. We were told that only one is used and this room did not have soap or hand towels available for staff to minimise the risk of cross infection. There was no toilet paper in the resident’s toilet downstairs. Other areas of the home were clean and there were no unpleasant odours. Ashdown Nursing Home DS0000062422.V367321.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s needs are met by the numbers of staff on duty. People are protected by the home’s recruitment procedures. The training programme is ongoing however not all staff have attended updates in the required training. EVIDENCE: There were sufficient numbers of staff on duty at the time of the site visit to meet the care needs of people living in the home. Samples of staff rotas were seen and showed that there are two registered nurses on duty at each shift, one person responsible for the care of people on the ground floor and the other nurse for people on the first floor. There are six care staff on duty and the manager said that they work in pairs because many people need support with mobility and some with behaviour issues. At night there is one registered nurse on duty and two carers. The manager confirmed that spot checks are made to make sure that night staff are supported and fulfilling their duties as recommended by the Social and Caring Services. During the day there were two cleaners who split the housekeeping tasks, one chef, a kitchen assistant, one person working in the laundry and a member of staff responsible for maintenance is on duty from 10.30am daily. The activities coordinator works from 10am until 2pm on weekdays. Ashdown Nursing Home DS0000062422.V367321.R01.S.doc Version 5.2 Page 20 Care staff are supported to achieve the National Vocational Qualification (NVQ) award at level two. Five of the fourteen care staff have achieved the award and two are registered on the programme. A sample of staff recruitment records were seen and showed that the required checks are carried out before people begin work. The manager said that she is committed to ensuring that the recruitment process is robust in order to protect people who live in the home. There is an induction and training programme. Staff spoken with said that they are encouraged to attend training courses. Nurses attend courses that support them in developing their professional skills including safe handling of medication and the care of people who have diabetes. The manager said that a new induction programme has been introduced that is in line with the Skills for Care guidance. The training records that were available showed that people have attended courses in the past year however it was not clear that all staff have received updates in mandatory training including safeguarding vulnerable adults. A requirement has been made regarding this matter. The records showed that three staff have attended dementia care training. All staff including the manager and activities coordinator should receive training in the care of people who have a dementia so that people are receiving the best possible care to meet their needs. A requirement has been made regarding this matter. Ashdown Nursing Home DS0000062422.V367321.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The newly appointed manager is not yet registered with the Commission. The views of some people involved with the home have been sought. People’s finances are protected by the procedures in the home. The health, safety and welfare of people in the home is not fully protected. EVIDENCE: The previous registered manager left the home in November and the registered provider was running the home until a month ago when the new manager was appointed. The person currently in post assisted with the site visit and is very enthusiastic about her new post. The manager designate has some management experience and is studying for the registered manager’s award; she has not yet undertaken training in the care of people who have a dementia. In order to ensure the business is run efficiently and effectively Ashdown Nursing Home DS0000062422.V367321.R01.S.doc Version 5.2 Page 22 meets with the regulations, then good support must be provided to the manager and an application submitted to the Commission. The provider carries out Regulation 26 visits to the home each month to make sure the business is running well; there was a copy of the monthly report on the notice board. Questionnaires are sent to relatives and a number had been returned. The results have not yet been collated and published to show that issues raised are being addressed. Comments made included: “My family and I have been very impressed with the welcome and the great care you have given my husband” and “An experienced team of staff who are dedicated to their work”. The manager was advised to consider ways to provide a questionnaire that would be more easily understood by people who live in the home and that other ways to ascertain their views about the home should be sought. There are procedures in place to protect people’s finances and the home does not act as appointee for anyone living there. There are measures in place to protect the health and safety of people living in the home and the AQAA states that equipment is serviced as required. It was not clear from the training records that all staff have attended mandatory training in the past twelve months in order to protect people living there. Incidents and accidents are recorded and the manager said that these are monitored to look for tends and to find ways to prevent accidents. Ashdown Nursing Home DS0000062422.V367321.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Ashdown Nursing Home DS0000062422.V367321.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP30 Regulation Reg 18 (1) (c) (i) Requirement All staff should be trained in providing care for people who have a dementia including the newly appointed manager and activities coordinator so that they understand the specialist needs of the people they care for. Measures must be taken to ensure that staff in charge of the home are aware of the reporting procedures regarding safeguarding matters to ensure that people are fully protected. All staff should receive updated training in safeguarding vulnerable adults to ensure that people living in the home are protected. Timescale for action 31/08/08 2. OP18 Reg 13 (6) 31/07/08 3. OP18 Reg 13 (6) 31/08/08 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 Good Practice Recommendations DS0000062422.V367321.R01.S.doc Version 5.2 Page 25 Ashdown Nursing Home Standard Ashdown Nursing Home DS0000062422.V367321.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ashdown Nursing Home DS0000062422.V367321.R01.S.doc Version 5.2 Page 27 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!