Inspection on 17/04/07 for Ashe Fields Residential Care Home

This inspection was carried out on 17th April 2007.

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

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 Ashe Fields Ash Lane Etwall Derby Derbyshire DE65 6HT Lead Inspector Steve Smith Unannounced Inspection 17th April 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ashe Fields DS0000069869.V337120.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. Ashe Fields DS0000069869.V337120.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashe Fields Address Ash Lane Etwall Derby Derbyshire DE65 6HT (01283) 734354 (01283) 734674 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 Nazim Ebraham Mr Mohammed Rafique Bhojani Mrs Pauline Anne Dickins Care Home 20 Category(ies) of Dementia (3), Old age, not falling within any registration, with number other category (20) of places Ashe Fields DS0000069869.V337120.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Date of last inspection 20th April 2006 Brief Description of the Service: Ashe Fields is a detached house in a rural setting approximately two miles from the village of Etwall. The care home provides social and personal care for up to 20 people aged 65 years and over, and also provides 2 day care places. All bedrooms are single rooms located on two floors, although none of the rooms have ensuite facilities. Access to the first floor is by stairs and a stair lift. The day areas include a large lounge, conservatory and dining room on the ground floor. Residents have access to well set out garden areas. The charges made for a room at Ashe Fields Care Home range from £308.50 to £340.10 a week. These charges are dependent on the needs of each Resident placed at the Home. Ashe Fields DS0000069869.V337120.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in just under 8.5 hours. Discussion was held with two Residents, and the records of three Residents were ‘case tracked’. Discussion was also held with the Manager of the Home, the Deputy Manager and with one member of the care staff. A number of records were examined, and all of the Residents bedrooms and all public areas of the Home were examined. The Commission’s pre-inspection questionnaire, sent to the Manager, was examined. The Commission’s Residents questionnaire was also sent to a selection of Residents, but none had been returned at the time of this inspection. What the service does well: The issues mentioned in these next three sections of the report were the items inspected on this visit to the Home. The Registered Providers and Manager had ensured that a statement of purpose and Residents Guide were in place, although some updates were required. However, the needs of all new Residents moving to the Home were appropriately assessed. Good records of care were maintained, as were the health care needs of the Residents, although again some improvements were needed. Medication issues were well met in the Home, although attention was needed in two areas. Two Residents were seen during this inspection, and they were most complimentary of staff, saying that their care needs were always well met. The Manager provided a good complaints procedure, and ensured that a good Safe Guarding Adults procedure operated within the Home. The Home was also maintained to a good physical standard throughout. The Manager was appropriately qualified and the Home was regularly ‘inspected’ by the Registered Providers. Some Quality Assurance issues were met, although some improvements were still needed. All Residents had been provided with a risk assessment to help in determining their safety. All accidents, injuries and incidents of illness or communicable diseases were recorded and reported to the relevant government bodies. The Registered Providers had also ensured that fire safety notices were posted in relevant places around the Home. Ashe Fields DS0000069869.V337120.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: It was found that the Registered Providers statement of purpose and Residents Guide did not include details of the physical environment standards which had been met and those which had not been met. The Residents Guide also lacked information on how contact could be made with the local Social Services Dept and local Health Authority. Following the Manager’s review of potential new Residents to the Home, she needed to send a letter to them stating that the Home would be able to meet their needs in respect of their health and welfare. Although the Manager undertakes a 6 monthly review of each Residents care needs she does not invite the Resident or their relatives to a meeting to discuss the Resident’s needs. The Manager also needed to indicate in each file that she has reviewed them on at least a monthly basis, and each Resident’s file also needed to contain a ‘confidential’ section. The Medication Administration Record sheets again were found to have a number of signature gaps on them. It was found that on occasions clothing was not always returned to the correct Resident by staff responsible for washing the clothing. The Manager was encouraged to extend the number of activities provided for Residents and to ensure that staff were aware of those able Residents who should be enabled to invite staff into their bedrooms. A choice of meal was not always offered at all main mealtimes, and those Residents who required a softened diet should not always receive a soup. The Manager needed to maintain a complete record of ‘concerns’ and ‘complaints’ within the Complaints file. Ashe Fields DS0000069869.V337120.R01.S.doc Version 5.2 Page 7 Attention was needed in one of the bathrooms to safeguard Residents, and the staff call bell was found to not be working in a bathroom and toilet. Two bedrooms were found to have a poor odour and so needed attention. Quality Assurance issues in the Home still needed further work to ensure they were fully addressed. The Manager also needed to ensure that risk assessments were carried out on all practice work topics undertaken by staff. 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. Ashe Fields DS0000069869.V337120.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 Ashe Fields DS0000069869.V337120.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): Standards 1, 2, 3 & 6. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. All new Residents moving to the Home were appropriately assessed prior to their admission, so that they were reassured that their needs would be met. EVIDENCE: The Registered Providers had provided a detailed statement of purpose for the Home together with a Resident’s Guide, which was available in each Residents bedroom. However, neither document clearly set out all of the physical environment standards met by the Home. The Residents Guide was well completed, and provided the opinions of Residents on what life was like in the Home. The Residents Guide also contained information on how contact could be made with the Commission, but not how to contact the local Social Services Dept or the local Health Authority. Ashe Fields DS0000069869.V337120.R01.S.doc Version 5.2 Page 10 The records of three Residents were examined during this inspection and a copy of the statement of terms and conditions of residency or a contract, if purchasing their care privately, was found in each file. When new Residents were admitted to the Home, the Manager was provided with a summary of the needs of each person, completed by the Social Services Dept Care Manager supporting each Resident, copies of which were seen. If the Residents were self-funding from the outset, the Manager completed her own summary of needs, which were also seen during the inspection. Standard 6 does not apply to this Home. Ashe Fields DS0000069869.V337120.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): Standards 7, 8, 9,10 & 11. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Residents’ health and personal care needs were being well met, as demonstrated within care plans. However, safe medication procedures needed to be updated to ensure that Residents health care needs were always met. EVIDENCE: To help assess Standard 7, the Resident’s Plan of Care, the records of three Residents were examined, for the purpose of case tracking. All of the basic information, concerning each Resident, was found to be in the files examined. This included details of the Resident, their next of kin, their Doctor, the Care Manager, from the Social Services Dept who assisted with the admission and the name of their keyworker in the Home. It was noted that in each Resident’s bedroom the name of the Keyworker was neatly provided on a notice on the wall. This was noted to be good practice. Ashe Fields DS0000069869.V337120.R01.S.doc Version 5.2 Page 12 However, the Manager said that when she had completed an assessment of a new Resident, and was of the opinion that the Home could provide a place for the person, she did not formally write to the person confirming that a place could be offered by the Home. A record of the Manager’s initial assessment of the needs of each Resident was detailed, and the files also contained a good, well maintained copy of the up to date care plan and risk assessment. The Manager had also ensured that Residents’ possible limitations of choice, freedom and decision-making abilities, if they were suffering from dementia, were formally recorded or reviewed at regular intervals. The files showed that good records of events affecting each Resident were kept by the Home. These included formal annual reviews undertaken by Social Services Dept personnel that included the Resident, their relatives and staff from the Home. The senior staff of the home also completed formal reviews, in the files seen, at two or three monthly intervals, but none of these reviews included the attendance of the Resident or their relatives. However, in addition, the keyworker for the Resident provided a written monthly update of the care needs and activities undertaken by each Resident. This was again deemed to be good practice by staff of the Home. Residents’ records were easy to read, with entries being made three or four time a day. The files were well organised, with different sections, and they were securely stored. However, there was no evidence to show that the Manager reviewed the files on a regular basis, although this was apparently done, and none of the files examined contained a confidential section. It was noted in the files seen that staff had recorded that certain Residents took themselves to bed at 10.00 pm or 11.00 pm. This was seen to be very positive for Residents. Staff were appropriately maintaining the records of Residents health needs. All medication and the method of distributing it to Residents was examined. A good system was found to be in use, although the following two issues required attention: A review of some of the Medication Administration Record (MAR) sheets was undertaken and 8 signature gaps were found. On one of the MAR sheets seen the Pharmacist had recorded ‘Take one at night’. The signature record showed that the medication was being Ashe Fields DS0000069869.V337120.R01.S.doc Version 5.2 Page 13 given in the morning. No handwritten up date was provided, on the MAR sheet, to indicate why this change in timing had taken place. Two Residents were spoken to about life in the Home. They said that staff were very good at listening to their views on how they liked to be cared for and staff would carry out their wishes. They also said that their care needs were always met with dignity and respect. As a result, they felt very safe in the Home, and appeared to have a strong sense and appearance of well being – ‘Staff check that I am able to safely do things for myself.’ ‘ Yes, everything is done most smoothly, staff are very good’. A member of staff was also interviewed; It was her opinion that she and her colleagues always respected Residents wishes, which was well supported by Residents opinions. Staff were over heard talking to Residents, throughout the inspection, and this was seen to be done in a quiet and respectful manner. The staff member said that a telephone was always available for Residents use, although they had to go down to the office to use it, as the Home did not have a cordless phone. Both Residents and the staff member said that mail was delivered to the Residents unopened. The staff member said that all clothing was appropriately marked with each Resident’s name, but said that not all staff took note of this. As a result, on fairly regular occasions, some Residents were found to be wearing other Residents clothing. The member of staff said that the term of address requested by the Residents was always used, even were the Resident requested to be formally addressed as Mrs or Mr. She also commented on the importance of the Home’s induction package for staff, that helped ensure that Residents were treated with respect at all times. Within the records of the three Residents files seen was an indication of each Resident’s choice of whether they wished to be buried or cremated following their death. The member of staff interviewed said that the Manager insisted that the privacy and dignity of dying Residents was always maintained. She also said that a dying Resident was always accompanied by a staff member, and that when the Resident had passed away time was always allowed for relatives to pay their last respects. Ashe Fields DS0000069869.V337120.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14, & 15. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Residents preferred lifestyles were respected by the Home, and Residents were given a wholesome and appealing diet in pleasant surroundings, that enhanced Residents well being. EVIDENCE: Two of the Residents were asked about the activities provided in the Home, but they had little memory of these events. The Deputy Manager and the staff member said that staff play bingo, cards and dominoes with Residents, and that a choir calls approximately once a month. They also said that day trips were organised 4 or 5 times year, and that the major Christian festivals were always marked. The two Resident said that they decided when they got up and went to bed – ‘I go to bed at 9.00 or 10.00 o’clock at night and I can get up in the morning when I like’. One Resident also said ‘I usually have one bath a week, but I can have extra baths if I want them’. Relatives and friends of Residents were able to visit at any time, and could always be seen in private - ‘I can always see my visitors in private’ ‘I see (my Ashe Fields DS0000069869.V337120.R01.S.doc Version 5.2 Page 15 relatives) in my bedroom’. The staff member interviewed said that relatives could visit at anytime. She also said that Residents could chose where they wanted to see their relatives, in the lounge, in the garden, in private in the conservatory or in their bedrooms. The member of staff also said that when new visitors first call to see a Resident, they were always asked to wait in reception while the Resident was asked whether they wished to see the new visitor. This was assessed as good practice. Both Residents also said that when staff came to the door of their bedrooms they knocked, paused and opened the door, they never waited to be invited in. This was also observed occurring during the inspection. Both Residents were able to say that a choice was available at mealtimes. However, the member of staff interviewed said that a choice was always available at breakfast and at the evening meal, but was not always available at all midday main meals. The member of staff also said that drinks and snacks were always provided between meals for Residents. She also said that mealtimes were never rushed, and that if a Resident required assistance from a member of staff to eat their meal this was always done on a one to one basis. On occasions Residents required liquefied/soft meals. The member of staff said that this was always provided as a soup, and never as individual separate food items. Ashe Fields DS0000069869.V337120.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Complaints made to the Registered Providers or Manager were addressed to meet Residents needs. The protection policies and procedures provided meant that Residents were well protected. EVIDENCE: One Resident was able to say that if he had a complaint to make he would tell Manager. The second Resident said that she would tell the first member of staff she saw. However, both Residents said that to date they had not had to make a complaint, despite knowing how to do so. The Commission had not received any notice of complaint since the last inspection of the Home in April 2006. Since that inspection, the Manager said that one record of complaint had been made in writing, which was reviewed and was found to be satisfactorily dealt with. However, she said that ‘concerns’ were not record in the complaints record kept by the Home, for example, if a Resident said that washed clothes had not been returned to them. Such records were maintained in Residents records. However, good procedures were seen for both written and verbal complaints. The Registered Providers’ complaints procedure detailed that all complaints would be responded to by a Registered Provider or the Manager within at least 28 days. Ashe Fields DS0000069869.V337120.R01.S.doc Version 5.2 Page 17 The Manager had a Safeguarding Adults procedure that included a ‘Whistle Blowing’ policy. She also had a copy of the Public Interest Disclosure Act of 1998, and of the Dept of Health’s policy called ‘No Secrets’ available in the Home. She confirmed that all allegations and incidents of abuse would be promptly followed up and that all actions taken would be recorded. The policies and practices laid down by the Registered Providers ensured that all staff understood physical and verbal aggression by Residents. The Manager also said that a policy was available to staff stating that they could not benefit from Residents wills, which was also confirmed by the staff member interviewed. Ashe Fields DS0000069869.V337120.R01.S.doc Version 5.2 Page 18 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): Standards 19, 20, 21, 22, 23, 24, 25, & 26. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. The Home was well maintained throughout, providing all Residents with a safe, comfortable environment in which to live. EVIDENCE: A tour was made of the Home, which included all of the bedrooms of the Residents. The Home was attractively decorated throughout, and the lounge and dining room were pleasant to sit in, and were provided with the appropriate items for the Residents. The bedrooms provided good space and provision for each Resident. The Registered Providers had provided appropriate furnishings in all locations seen during the inspection. Toilets were easily available to all Residents, were clearly marked, and were provided with handrails where necessary. A call system was available Ashe Fields DS0000069869.V337120.R01.S.doc Version 5.2 Page 19 throughout the Home. All bedroom doors were provided with locks, which Residents could chose to use. All radiators were appropriately guarded, and could be controlled within each bedroom. The Home had appropriate sluicing facilities, and laundry was washed at appropriate temperatures. However, the following items were seen to need addressing within the Home: The bathroom, provided on the first floor, was fitted with a hoist that could not be locked in position. This meant that a Resident could still move the hoist seat from side to side when in the bath and possibly trap their hands or the flesh on their legs. The call bell on the first floor in the bathroom and adjoining toilet was not operating at the time of this inspection. The staff call system provided in all places around the Home was found to be very old. Staff reported that the system was ‘old fashioned’ and took a long time to obtain repairs. The system was provided with a button to call for assistance, which was situated right next to the button for staff to cancel the call. Therefore, a Resident could easily call for assistance, and then cancel the call by pressing the wrong button when calling again for assistance, if help was delayed for a short time. A more modern system was required. A poor odour was found in two bedrooms. The Deputy Manager said that the Home did not have its own carpet cleaner, and only hired one at intervals; approximately three monthly. The bedroom carpets identified needed cleaning much more frequently; the Home should obtain its own carpet cleaning equipment to allow this to happen. Ashe Fields DS0000069869.V337120.R01.S.doc Version 5.2 Page 20 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): Standards 27, 28, 29 & 30. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. The amount of care staffing provided needed to improve to ensure that Residents needs could always be met. EVIDENCE: Staffing provided in the Home was found to be satisfactory and met the needs of Residents. At the time of this inspection it was found that more than 50 of care staff had a qualification of at least NVQ level 2 in Care, and therefore surpassed the expectation of the Commission. The staff member interviewed said that she held an NVQ level 3 in Care. The recruitment procedure to be followed by the Home was examined and it was found that no new staff had been employed since the last inspection in April 2006. This very positive position meant that it was not possible to check the recruiting procedure followed, to ensure it met that laid down by Regulation 19 and Schedule 2 of The Care Homes Regulations 2001. The Deputy Manager said that new staff would be provided with induction and foundation training. She also said that all care staff were provided with at least three paid days training a year, and a member of the care staff provided Ashe Fields DS0000069869.V337120.R01.S.doc Version 5.2 Page 21 corroboration. The records of some of this training was seen. All staff also had an individual training and development assessment and profile. Ashe Fields DS0000069869.V337120.R01.S.doc Version 5.2 Page 22 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): Standards 31, 33, 35, 36 & 38. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Staff received regular training and supervision to ensure that Residents needs were always met. EVIDENCE: The Manager was appropriately qualified to manage the Home, having an NVQ level 4 qualification in Management and Care. The records of the monthly ‘inspections’ of the Home, carried out by the Registered Providers, were examined and found to be in good order. The Deputy Manager was able to show the annual development plan for the Home that reflected the aims and outcomes for Residents. She also stated that she, the Manager and the staff would be able to demonstrate the Home’s commitment to lifelong learning and development of each Resident in the Ashe Fields DS0000069869.V337120.R01.S.doc Version 5.2 Page 23 Home. This was also confirmed by the member of care staff interviewed. Surveys had been undertaken of Residents opinions of the operation of the Home, although these had not been published. The opinions of Residents families and friends or of GPs or District Nurses were not obtained on how well they thought the Home was achieving goals for Residents. The Deputy Manager stated that the Home does not hold any savings money for Residents. Residents purchases and hairdressing etc were paid by the Home and relatives were then billed for these amounts. The member of staff interviewed was asked whether she received regular supervision from the Manager or Deputy Manager, and she said that this was done on a monthly/bi-monthly basis by the Deputy Manager. This was later confirmed by the Deputy Manager. The training required by the Regulations was examined. This showed that Moving and Handling training, First Aid training, Food Hygiene training and Infection Control training were all up to date. Fire Safety training had been provided for all staff except one member of the night team who was in need of one addition training event. The Deputy Manager was encouraged to ensure that at least one qualified First Aider was on duty on every shift in the home, both day and night. However, she said that only one member of staff currently held the First Aider qualification. In addition to the above required training, the Deputy Manager said that training was also provided on Dementia Awareness, Visual Awareness and Health and Safety. All Residents had been risk assessed to determine their vulnerability and measures had been put in place to provide protection where necessary. From copies of the Home’s maintenance schedule, forwarded to the Commission prior to the inspection, it was found that all necessary maintenance and repairs were being appropriately addressed. The Deputy Manager was able to show that the Manager had started to provide risk assessments on the working conditions of staff; that is for care staff, catering staff and domestic staff, but this required a lot more detail to be complete. The Deputy Manager was also able to show that all accidents, injuries and incidents of illness or communicable disease were recorded and reported to the relevant government bodies. With the assistance of the Fire Service, fire safety notices were also posted in relevant places around the Home. Ashe Fields DS0000069869.V337120.R01.S.doc Version 5.2 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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 2 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 2 Ashe Fields DS0000069869.V337120.R01.S.doc Version 5.2 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 OP7 Regulation 14(1)(d) Requirement Each new Resident’s file must contain a copy of a letter sent to the Resident, prior to admission, to say that the services provided in the Home are suitable to meet the Resident’s needs in respect of their health and welfare. (This issue is outstanding from the inspection report dated 20 April 2006) Signature gaps on the Medication Administration Record (MAR) sheet must be followed up by the Manager. She should indicate on the back of the relevant MAR sheet why the gap occurred and her action when following this up. (This issue is outstanding from the inspection report dated 20 April 2006) Medication must be given as detailed on the MAR sheet. If a Doctor has authorised a change, this must be recorded on the MAR sheet together with the signature of the two staff who handled the change. Ashe Fields DS0000069869.V337120.R01.S.doc Version 5.2 Page 26 Timescale for action 12/06/07 2. OP9 13(2) 12/06/07 3. OP19 23(2)(n) Bathroom hoists must be able to lock into position, to protect Residents from damaging their flesh when using them. The staff call bell in the bathroom and toilet on the first floor must be urgently repaired. The Registered Providers and Manager must address all of the Quality Assurance issues listed within Standard 33.1 to 33.7. (This issue is outstanding from the inspection report dated 20 April 2006) Fire Safety training must be provided for all night staff twice a year. The Manager must provide risk assessments on all working practice topics in order to ensure that significant findings are recorded and acted upon. 12/06/07 4. OP22 23(2)(n) 12/06/07 5 OP33 24 30/09/07 6. OP38 23(4)(d) & (e) 18(1)(a) & (c)(i) 31/07/09 7. OP38 31/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Refer to Standard OP1 No. 1. Good Practice Recommendations The statement of purpose should include details of the physical environment standards met by the Home, and these should be summarised in the Residents Guide. The Residents Guide should include information on how contact can be made with the local Social Services Dept and local Health Authority. Ashe Fields DS0000069869.V337120.R01.S.doc Version 5.2 Page 27 (These issues were outstanding from the inspection report dated 20 April 2006) 2. OP7 The Manager should formally review each Resident’s care plan and risk assessment at 6 monthly intervals. The formal review should include the Resident, their representative and, if appropriate, their other relatives, the Manager and other involved staff. One of these reviews could be conducted by the Social Services Dept, although the Manager should provide formal written input to the review of the welfare and care provide to the Resident. The Manager should review each Resident’s file on a least a monthly basis. She could indicate that this has been done by signing the record with a red or green pen. (This issue is outstanding from the inspection report dated 20 April 2006) All Residents files should contain a ‘confidential’ section. 3. 4. OP10 OP12 The staff of the Home should ensure that Residents wear their own clothing at all times. The Registered Provider should ensure that a wide range of activities are provided on an individual and group basis for all Residents. This could be done by employing an Activities Coordinator on at least a three day a week basis. Staff should be made aware of those Residents who should be encouraged, following staff knocking on their bedroom door, to invite staff into their bedrooms and those Residents who can no longer do this. 5. OP15 A choice should be offered to Residents at all mealtimes. When Residents require liquefied/soft meals, this should always be done by softening the food items on an individual basis and not by providing a soup. 6. OP16 The Manager should keep a record of all concerns and complaints, whether provided in writing or verbally, showing the nature of the complaint and what the Manager has done about the complaint/concern. The odour in the two bedrooms identified during the inspection needed to be urgently removed. This might be done by much more frequent carpet cleaning or removing DS0000069869.V337120.R01.S.doc Version 5.2 Page 28 7. OP19 Ashe Fields the carpeting and replacing with a cushion flooring. A carpet cleaner should be purchase for use in the Home. A new call bell system could be installed in the Home. 8. OP38 Sufficient senior staff should be trained as First Aiders to ensure that at least one First Aider is on duty on each shift, both day and night. (This issue is outstanding from the inspection report dated 20 April 2006) Ashe Fields DS0000069869.V337120.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Ashe Fields DS0000069869.V337120.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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