Inspection on 07/11/06 for Ashfield House Nursing Home

This inspection was carried out on 7th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashfield House Nursing Home 23/10/08

Ashfield House Nursing Home 28/02/06

Ashfield House Nursing Home 18/10/05

Ashfield House Nursing Home 05/10/04

Ashfield House Nursing Home 23/06/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

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

CARE HOME ADULTS 18-65 Ashfield House Nursing Home Thornton Road Thornton Bradford West Yorkshire BD13 3LN Lead Inspector Linda Trenouth Key Unannounced Inspection 7th November 2006 9:30 Ashfield House Nursing Home DS0000019913.V310933.R01.S.doc Version 5.2 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 Ashfield House Nursing Home DS0000019913.V310933.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 Adults 18-65. 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. Ashfield House Nursing Home DS0000019913.V310933.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashfield House Nursing Home Address Thornton Road Thornton Bradford West Yorkshire BD13 3LN 01274 833133 01274 833856 louise.baines@brunelhousing.orguk 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) Brunel & Family Housing Association Limited Miss Louise Baines Care Home 19 Category(ies) of Learning disability (19) registration, with number of places Ashfield House Nursing Home DS0000019913.V310933.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th February 2006 Brief Description of the Service: Ashfield House is a large converted home located in a rural position on the outskirts of Thornton village, a few miles west of Bradford. The home has extensive grounds and is set in a picturesque location. Local transport facilities are situated near by and the shops and facilities of Thornton are close to hand. Accommodation is provided in single rooms and one shared room on the lower ground, ground and first floors with wheelchair access throughout the home. There are lifts to all levels. The home has two lounge areas and a large dining room. The home also has a (multi sensory) Snoozelan room. The home is a joint venture between Brunel Support Works Ltd and Bradford Health Trust, providing long term nursing care for adults with learning disabilities. Ashfield House Nursing Home DS0000019913.V310933.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example, “ Choice of Home” and “Leisure.” An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent,” “good”, “adequate” and “poor.” The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk This was an unannounced key inspection carried out by one inspector who was at the home for approximately 7 hours. The main purpose of this inspection was to make sure that the home provides a good standard of care for the residents. The methods used at this inspection included looking at records, observing working practices, and talking to residents and staff. Comment cards were sent to residents, relatives and visiting health and social care professionals giving then an opportunity to comment on the service. Findings from those comment cards are included in this report. Feedback was given to the registered manager Louise Baines at the end of the visit. Requirements and recommendations made during this visit, and outstanding from previous inspection visits can be found at the end of the report. What the service does well: The relatives and residents are provided with sufficient information in the service user guide and statement of purpose to make an informed choice about the service. The manager and staff enable and encourage residents to make decisions and take risks in their day to day lives and involve them in the planning of their care. Ashfield House Nursing Home DS0000019913.V310933.R01.S.doc Version 5.2 Page 6 There is good record keeping and monitoring to ensure that all healthcare needs are appropriately met. The meals are nourishing and appear to provide the residents with a varied and balanced diet, the cook and care staff involve individuals in making a choice at meal times. The home continues to improve with decorations of bedrooms now complete and communal areas refurbished. The manager has identified other areas that require improvement and staff constantly monitor where repairs and maintenance are required. The staff continue to maintain a comfortable and safe environment. The manager strives to ensure a good quality of care is provided for all individuals and gives service users and their relatives the opportunity to express their opinions and be involved in decision making within the home. What has improved since the last inspection? What they could do better: The copy of the contract or terms and conditions between the home and the resident must be available to the residents or their relatives at all times to ensure that the individual is aware of their rights whilst living at the home. Ashfield House Nursing Home DS0000019913.V310933.R01.S.doc Version 5.2 Page 7 The residents or their representatives must sign and give their consent to the administration of medication and to agree the content of the care plan. Whilst the manager ensures regular team meetings for staff, individual supervision must be undertaken at regular intervals. Training should be fully audited and all staff must have training in learning disabilities to provide underpinning knowledge and safely meet the needs of residents. Training in adult protection must be provided for all staff and appropriate medication training must be provided to staff where they are asked to witness the administration of controlled drugs. The manager has completed a quality assurance questionnaire survey of residents and relatives, which is seen as good practice. The quality survey must however be developed further to include the views of staff, advocates and of stakeholders in the community (e.g. GP’s, chiropodist, audiologist, day care staff, social workers, voluntary organisation staff). An Annual report must then be produced of the findings and available to everyone, including the CSCI. 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. Ashfield House Nursing Home DS0000019913.V310933.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashfield House Nursing Home DS0000019913.V310933.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The relatives and residents are provided with sufficient information to make an informed choice about the service. The contract or terms and conditions between the home and the resident must be available to them at all times to ensure that the individual is aware of their rights whilst living at the home. EVIDENCE: There have been no new admission to the home for some time, the last admission had a core assessment and had had several visits to the home and overnight stays prior to moving in. A copy of the service user guide is made available to residents and their relatives, all information is available in a easy read pictorial style to met differing communication needs The individual contract or terms and conditions was not available to residents. While the inspector is aware that this documentation has previously been completed and was made available in an easy read form, concerns were raised that this documentation, outlining peoples rights was no longer available to the residents at the home. Ashfield House Nursing Home DS0000019913.V310933.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. Staff treat residents with repect and help them make decisions and take risks in their day to day lives. Staff encourage residents to participate meaningfully in their care planning. EVIDENCE: It is good practice that the residents are involved with their assessments and care plans but individuals or their representatives must sign their care plans and reviews to confirm their involvement and consent. Discussion with the staff and review of records confirmed that care planning reviews and updating of assessments have been done. The manager and staff have implemented a type of person centred planning approach, with the introduction of the, “my plan” document. Each of the residents have Ashfield House Nursing Home DS0000019913.V310933.R01.S.doc Version 5.2 Page 11 participated in the decision making and gathering of information for this document. Outcomes from this have been transferred into the current care records. The balance of focus on health and social care needs has improved but needs to develop further, whilst the health care needs play an important role in effective care panning the social care needs of an individual are equally important. All staff, nursing and carers, must be involved with the social care planning aspect and better balance achieved. The residents are encouraged in making decisions and enjoying activities both in and beyond the home. One resident recently took up horse riding at a local stables and said that he wanted to keep going as he enjoyed the activity and had been helped to feel safe. He also enjoyed bowling and going to the pictures. Residents also said that they took part in the residents’ forum and discussed food, activities and places they would like to visit. Ashfield House Nursing Home DS0000019913.V310933.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the 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, 16 and 17. Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to join in leisure/social activities and to exercise choice and control of their lives. Meals are nourishing and appear to provide the residents with a varied and balanced diet. EVIDENCE: The daily routines of the home appear flexible and continue to be based around the needs of the residents. Residents are encouraged to be as independent as possible and make informed decisions and choices about their daily lives. During the course of the visit residents relaxed and appeared comfortable. There was a friendly banter between staff and residents and staff clearly had a good understanding of the communication needs of individual residents. Ashfield House Nursing Home DS0000019913.V310933.R01.S.doc Version 5.2 Page 13 There is an activities plan for the week and resident’s individual needs are assessed. There is an activities coordinator and staff also promote and encourage activities. The activities include, make up, nails, aromatherapy sessions, sensory room, shopping, walks, bingo, art activity, picnics and baking, bowling, cinema and horse riding. Recent trips people had enjoyed included Blackpool and Cleethorpes. The manager explained that it wasn’t always possible to ensure all residents had a holiday. They could not always meet individual choice, as funding and staff cover was an issue. Some individuals have been on day trips to places such as Blackpool and two residents have been to Holland but this had been reliant on staff goodwill. Where people wish to have a holiday and this is within their contract they must be supported to do so. During the course of the visit the residents had lunch. The cook discussed the choice and range of diets that are available. The cook has a good understanding of nutritional need and has attended relevant training to meet individual dietary need. The menus were reviewed prior to the visit to the home and were found to be varied and nutritious. The cook and staff confirmed that individual discussions and observations of residents confirmed their personal likes and dislikes of food. The residents’ forums also give the chance for food to be discussed and ideas suggested. The mealtimes at the home are relaxed and unhurried and residents requiring assistance are helped in a discreet and sensitive manner. One resident told the inspector that she sets the tables for every mealtime and likes to help out doing things to keep her busy. Ashfield House Nursing Home DS0000019913.V310933.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. Healthcare needs are appropriately met. Comment cards confirmed that dignity was respected and personal and health care was undertaken in the privacy of the individual’s own room. General medication is managed and administered safely but the witnessing of controlled drugs must be undertaken by an individual who has had appropriate medication training. EVIDENCE: From discussions with staff and review of the records it was clear that staff managed complex health care needs. Staff had access to comprehensive health care training to meet those needs. The manager confirmed that the staff team continue to monitor the health and general well being of residents taking long-term medication and repeat prescriptions continue to be reviewed regularly by their general practitioner. Ashfield House Nursing Home DS0000019913.V310933.R01.S.doc Version 5.2 Page 15 Visiting health care professionals confirmed that they felt that medication was handled appropriately and confirmed that any advice they give is incorporated into the care plan. The medication records were completed and storage was safe. The controlled medication record was reviewed and it was confirmed that a health care assistant could witness the administration of the medication but that they must have had appropriate training. The care plan must also acknowledge the consent of an individual to have medication administered to them, it may be necessary in some cases to ask a relative to consent to this on the resident’s behalf. Ashfield House Nursing Home DS0000019913.V310933.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome is adequate. This judgement has been made using available evidence including a visit to this service. Residents and their relatives have their views listened to, taken seriously and action is taken to resolve issues. Training and appropriate consultation needed to improve to ensure that residents were adequately protected from abuse. EVIDENCE: The residents meet regularly in the residents’ forums and relatives are invited to the home to events throughout the year. Questionnaires are also sent to both residents and relatives to ask their opinion of the care they receive. The manager and staff take concerns raised seriously and respond promptly. Complaints procedures are displayed and available in the service user guide and contract information. The residents have named nurses and care workers who help coordinate their reviews. The review meetings give further opportunities for concerns to be raised and problems resolved. The manager and senior staff audit financial transactions and each resident has their own bank account. The appointee for the residents is based at Brunel and is independent of the staff and management of the home. The residents are not able to manage their own monies and policies are in place to ensure that Ashfield House Nursing Home DS0000019913.V310933.R01.S.doc Version 5.2 Page 17 all transactions made on their behalf are transparent. The manager monitors all transactions and individual bank accounts. Concerns were raised at the inspection about residents’ monies being used to finance the leasing of a minibus for the home. Residents who were in receipt of additional benefits were charged, but the extent to which they had agreed to or been consulted was unclear. Appropriate consultation and agreements must be undertaken before any such arrangements can be made. Concerns were also raised that not all staff had completed adult protection training and others may require up-dates. Ashfield House Nursing Home DS0000019913.V310933.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 30. Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. Residents live in a clean, comfortable and safe environment, which meets their needs. EVIDENCE: The condition of the building continues to improve. The areas of the home continue to be very clean and well maintained. Communal and individual space presently meets the agreed standard with the provision of three communal rooms on the ground floor. The decoration and furniture is homely with comfortable furniture and good decor throughout. All of the residents’ bedrooms were seen. They were well decorated and reflected the choices and tastes of the individual. It was clear that residents are encouraged to buy furniture and items to individualise their rooms. All rooms were comfortable and adapted to meet the health needs of individuals, thought had been given to visual stimulation for individuals who spend time Ashfield House Nursing Home DS0000019913.V310933.R01.S.doc Version 5.2 Page 19 more time resting in their rooms and lighting levels were adjustable in all bedrooms. The home is looking good with the windows of the house and conservatory having been recently replaced, and extensive redecoration throughout. The car park and drive have been resurfaced. The gardens continue to be well maintained. Further attention was required to the first floor bathroom door and some fire doors require adjustment. Lampshades must be fitted on the first floor corridor to provide a more comfortable homely effect. The home has good infection control policies and staff spoken to had a good understanding of health and safety requirements in the home. All staff have had health and safety and infection control training. Clinical and medication waste was well organised and collected regularly. Staff confirmed that gloves, aprons, and appropriate cleaning aids were readily available throughout the home. The laundry room was well organised and managed, the home has designated laundry staff and night staff complete the ironing. Cleaning staff in the home are rigorous in maintaining a good standard of cleanliness throughout the building. The staff said they felt well supported and clearly took pride in their work. Storage was generally good throughout the home with the exception of the resident’s telephone area. Unfortunately this had become an area for storing various items including bags and a minibus seat. These items must be cleared. Ashfield House Nursing Home DS0000019913.V310933.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34, 35 and 36. Quality in this outcome is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the manager ensures regular team meetings for staff individual supervision must be undertaken at regular intervals. Training must be audited and all staff must have training in the learning disabilities award framework to provide the underpinning knowledge. EVIDENCE: The Induction and mandatory training for all staff is generally good, they also have opportunities to attend courses that increase their knowledge and expertise. Training undertaken has mostly been focused on the medical needs of the residents and the manager works hard to ensure that all the residents’ health needs are met. Not all staff, have had sufficient training in learning disabilities. The staff team remain stable with few staff leaving the service. The manager said that there were some vacancies at the home but these were being addressed and did not effect the overall staffing levels. Recruitment was Ashfield House Nursing Home DS0000019913.V310933.R01.S.doc Version 5.2 Page 21 reviewed but no new staff have been recruited and employed at the home but staff have transferred from other learning disabilities homes in Bradford. Staff supervision was being undertaken but not regularly enough, concerns were expressed that one member of staff who had transferred from another home in May had not had any formal supervision. Supervision must be undertaken a minimum of every two months. Ashfield House Nursing Home DS0000019913.V310933.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 and 43. Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. The home has systems in place to seek the views of residents, relatives and staff. Records are detailed and provide good information about events that have taken place. The health and safety of residents and staff are protected but regular auditing and review of safety checks. EVIDENCE: Health and Safety audits are regularly undertaken in key areas of the home. This presently is divided between the two organisations Bradford Health Care Trust and Brunel Housing. Ashfield House Nursing Home DS0000019913.V310933.R01.S.doc Version 5.2 Page 23 The manager has further delegated roles to staff to audit such as medication, infection control and residents’ monies. Visits by the registered provider are not being undertaken regularly enough. These visits must be monthly to ensure sufficient support to the manager of the home and adequate monitoring of health and safety and the quality of care at the home. The manager had undertaken her own quality survey, which is good practice, and has had a good response from residents and relatives. The manager has responded promptly to comments raised by relatives in the survey. This annual review, however must be developed further to include more people i.e. staff, GP’s Social Workers, Chiropodists and other individuals and groups in the community. An annual report of the findings must be produced and distributed to people using and involved in the service. The manager has had many years experience in working with people with learning disability, and has completed the NVQ in management. The home is well organised and run and staff feel supported in their work. The building is maintained safely and the improvements to the environment are a reflection of the manager and staff working to the provision of a good quality of life for the residents. The home has been consistently well managed over the last three years, it has had committed leadership and this has ensured the home has developed into a good home for both residents and staff. Ashfield House Nursing Home DS0000019913.V310933.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 Adults 18-65 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 4 2 3 3 x 4 x 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 4 26 x 27 x 28 x 29 x 30 4 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 2 x 3 4 2 x x 4 3 Ashfield House Nursing Home DS0000019913.V310933.R01.S.doc Version 5.2 Page 25 yes 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 2 Standard YA5 YA6 Regulation 5 15 Requirement Timescale for action 10/01/07 3 YA14 16 All residents must have a contract or terms and conditions. Residents or their 10/01/07 representatives must sign and give their consent to the administration of medication and to agree the content of the care plan. Residents must be given a choice 10/01/07 how they wish to spend their recreation and leisure time and supported in an annual holiday if this is their choice. Medication training must be provided to carers where they are asked to witness the administration of controlled drugs. The manager must provide evidence of the consultation and agreement with residents and their relatives/ advocates regarding the leasing of the minibus. Adult protection training and updates must be provided for all staff. 10/01/07 4 YA20 13 5 YA23 13 10/01/07 6 YA23 13 10/01/07 Ashfield House Nursing Home DS0000019913.V310933.R01.S.doc Version 5.2 Page 26 8 YA24 23 Items stored outside the lift area must be removed and the area where the residents’ telephone is sited made comfortable. Fire doors must be adjusted to be safe and light shades fitted to corridor. The bathroom door on the first floor must be adjusted. Previous timescale 30/01/06 and 30/04/06 not met. All staff must have training in the learning disabilities award framework to provide the underpinning knowledge to meet the needs of the residents. All staff must have regular supervision. The responsible individual or their representative must undertake monthly visits to the home and produce a report, a copy of which must be sent to the CSCI at Rodley. The quality survey must be developed further to include staff and stakeholders. An Annual report must be produced of the findings and available to everyone, including the CSCI. 10/01/07 9 YA26 23 10/01/07 10 YA35 12 10/01/07 11 12 YA36 YA39 18 26 10/01/07 10/01/07 13 YA39 24 10/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA35 Good Practice Recommendations A full training audit should be undertaken of all staff to ensure that all training and updates of training are met. Ashfield House Nursing Home DS0000019913.V310933.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Ashfield House Nursing Home DS0000019913.V310933.R01.S.doc Version 5.2 Page 28 - 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!